Association of Plasma Amyloid-β and Dementia Among Black and White Older Adults

Background

Plasma amyloid-β (Aβ) has emerged as an important tool to detect risks of Alzheimer's disease and related dementias, although research in diverse populations is lacking.

Objective

We compared plasma Aβ 42/40 by race with dementia risk over 15 years among Black and White older adults.

Methods

In a prospective cohort of 997 dementia-free participants (mean age 74±2.9 years, 55% women, 54% Black), incident dementia was identified based on hospital records, medication, and neurocognitive test over 15 years. Plasma Aβ 42/40 was measured at Year 2 and categorized into low, medium, and high tertile. We used linear regression to estimate mean Aβ 42/40 by race and race-stratified Cox proportional hazards models to assess the association between Aβ 42/40 tertile and dementia risk.

Results

Black participants had a lower age-adjusted mean Aβ 42/40 compared to White participants, primarily among APOE ɛ4 non-carriers (Black: 0.176, White: 0.185, p = 0.035). Among Black participants, lower Aβ 42/40 was associated with increased dementia risk: 33% in low (hazard ratios [HR] = 1.77, 95% confidence interval 1.09-2.88) and 27% in medium tertile (HR = 1.67, 1.01-2.78) compared with 18% in high Aβ 42/40 tertile; Increased risks were attenuated among White participants: 21% in low (HR = 1.43, 0.81-2.53) and 23% in medium tertile (HR = 1.27, 0.68-2.36) compared with 15% in high Aβ 42/40 tertile. The interaction by race was not statistically significant.

Conclusions

Among community-dwelling, non-demented older adults, especially APOE ɛ4 non-carriers, Black individuals had lower plasma Aβ 42/40 and demonstrated a higher dementia risk with low Aβ 42/40 compared with White individuals.

Cognitive and Functional Trajectories in Older Adults With Prediagnostic Parkinson Disease

BACKGROUND AND OBJECTIVES

There is increasing interest in characterizing the earliest phases of Parkinson's Disease (PD). However, few studies have investigated prediagnostic trajectories of cognition and function. Our objective was to describe prediagnostic cognitive and functional trajectories in PD in older women and men.

METHODS

We studied 9,595 women and 5,795 men from two prospective cohort studies of community-dwelling elders followed up to 20 years. In individuals without prevalent PD, we estimated the associations of incident PD diagnosis with rates of change in cognition and function before and after diagnosis compared to healthy older adults using multivariate mixed-effects models.

RESULTS

Over follow-up, 297 individuals developed incident PD. Interactions between the terms in our model and sex were statistically significant for the three outcomes (p<0.001 for all), so we stratified results by sex. Compared to older men without PD, men who developed PD exhibited faster decline in global cognition (0.04 SD more annual change, p<0.001), executive function (0.05 SD more annual change, p<0.001), and functional status (0.06 SD more annual change, p<0.001) in the prediagnostic period. Women who developed PD compared to women without PD displayed faster decline in executive function (0.02 SD more annual change, p=0.006) and functional status in the prediagnostic period (0.07 SD more annual change, p<0.001).

DISCUSSION

Individuals with incident PD exhibit cognitive and functional decline during the prediagnostic phase that exceeds rates associated with normal aging. Better understanding heterogeneity in prodromal PD is essential to enable earlier diagnosis and identify impactful nonmotor symptoms in all subgroups.

Early to Midlife Smoking Trajectories and Cognitive Function in Middle-Aged US Adults: the CARDIA Study

BACKGROUND

Smoking starts in early adulthood and persists throughout the life course, but the association between these trajectories and midlife cognition remains unclear.

OBJECTIVE

Determine the association between early to midlife smoking trajectories and midlife cognition.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants were 3364 adults (mean age = 50.1 ± 3.6, 56% female, 46% Black) from the Coronary Artery Risk Development in Young Adults (CARDIA) study: 1638 ever smokers and 1726 never smokers.

MAIN MEASURES

Smoking trajectories were identified in latent class analysis among 1638 ever smokers using smoking measures every 2-5 years from baseline (age 18-30 in 1985-1986) through year 25 (2010-2011). Poor cognition was based on cognitive domain scores ≥ 1 SD below the mean on tests of processing speed (Digit Symbol Substitution Test), executive function (Stroop), and memory (Rey Auditory Verbal Learning Test) at year 25.

RESULTS

Five smoking trajectories emerged over 25 years: quitters (19%), and minimal stable (40%), moderate stable (20%), heavy stable (15%), and heavy declining smokers (5%). Heavy stable smokers showed poor cognition on all 3 domains compared to never smoking (processing speed AOR = 2.22 95% CI 1.53-3.22; executive function AOR = 1.58 95% CI 1.05-2.36; memory AOR = 1.48 95% CI 1.05-2.10). Compared to never smoking, both heavy declining (AOR = 1.95 95% CI 1.06-3.68) and moderate stable smokers (AOR = 1.56 95% CI 1.11-2.19) exhibited slower processing speed, and heavy declining smokers additionally had poor executive function. For minimal stable smokers (processing speed AOR = 1.12 95% CI 0.85-1.51; executive function AOR = 0.97 95% CI 0.71-1.31; memory AOR = 1.21 95% CI 0.94-1.55) and quitters (processing speed AOR = 0.96 95% CI 0.63-1.48; executive function AOR = 0.98 95% CI 0.63-1.52; memory AOR = 0.97 95% CI 0.67-1.39), no association was observed.

CONCLUSIONS

The association between early to midlife smoking trajectories and midlife cognition was dose-dependent. Results underscore the cognitive health risk of moderate and heavy smoking and the potential benefits of quitting on cognition, even in midlife.

Remote Assessment of Cardiovascular Risk Factors and Cognition in Middle-Aged and Older Adults: Proof-of-Concept Study

Background

Adults with cardiovascular disease risk factors (CVRFs) are also at increased risk of developing cognitive decline and dementia. However, it is often difficult to study the relationships between CVRFs and cognitive function because cognitive assessment typically requires time-consuming in-person neuropsychological evaluations that may not be feasible for real-world situations.

Objective

We conducted a proof-of-concept study to determine if the association between CVRFs and cognitive function could be detected using web-based, self-administered cognitive tasks and CVRF assessment.

Methods

We recruited 239 participants aged ≥50 years (mean age 62.7 years, SD 8.8; 42.7% [n=102] female, 88.7% [n=212] White) who were enrolled in the Health eHeart Study, a web-based platform focused on cardiac disease. The participants self-reported CVRFs (hypertension, high cholesterol, diabetes, and atrial fibrillation) using web-based health surveys between August 2016 and July 2018. After an average of 3 years of follow-up, we remotely evaluated episodic memory, working memory, and executive function via the web-based Posit Science platform, BrainHQ. Raw data were normalized and averaged into 3 domain scores. We used linear regression models to examine the association between CVRFs and cognitive function.

Results

CVRF prevalence was 62.8% (n=150) for high cholesterol, 45.2% (n=108) for hypertension, 10.9% (n=26) for atrial fibrillation, and 7.5% (n=18) for diabetes. In multivariable models, atrial fibrillation was associated with worse working memory (β=-.51, 95% CI -0.91 to -0.11) and worse episodic memory (β=-.31, 95% CI -0.59 to -0.04); hypertension was associated with worse episodic memory (β=-.27, 95% CI -0.44 to -0.11). Diabetes and high cholesterol were not associated with cognitive performance.

Conclusions

Self-administered web-based tools can be used to detect both CVRFs and cognitive health. We observed that atrial fibrillation and hypertension were associated with worse cognitive function even in those in their 60s and 70s. The potential of mobile assessments to detect risk factors for cognitive aging merits further investigation.

Cardiovascular risk factors and accelerated cognitive decline in midlife: The CARDIA Study

OBJECTIVE

Increasing evidence supports an association between midlife cardiovascular risk factors (CVRFs) and risk of dementia, but less is known about whether CVRFs influence cognition in midlife. We examined the relationship between CVRFs and midlife cognitive decline.

METHODS

In 2,675 black and white middle-aged adults (mean age 50.2 ± 3.6 years, 57% female, 45% black), we measured CVRFs at baseline: hypertension (31%), diabetes mellitus (11%), obesity (43%), high cholesterol (9%), and current cigarette smoking (15%). We administered cognitive tests of memory, executive function, and processing speed at baseline and 5 years later. Using logistic regression, we estimated the association of CVRFs with accelerated cognitive decline (race-specific decline ≥1.5 SD from the mean change) on a composite cognitive score.

RESULTS

Five percent (n = 143) of participants had accelerated cognitive decline over 5 years. Smoking, hypertension, and diabetes mellitus were associated with an increased likelihood of accelerated decline after multivariable adjustment (adjusted odds ratio [AOR] 1.65, 95% confidence interval [CI] 1.00-2.71; AOR 1.87, 95% CI 1.26-2.75; AOR 2.45, 95% CI 1.54-3.88, respectively), while obesity and high cholesterol were not associated with risk of decline. These results were similar when stratified by race. The likelihood of accelerated decline also increased with greater number of CVRFs (1-2 CVRFs: AOR 1.77, 95% CI 1.02-3.05; ≥3 CVRFs: AOR 2.94, 95% CI 1.64-5.28) and with Framingham Coronary Heart Disease Risk Score ≥10 (AOR 2.29, 95% CI 1.21-4.34).

CONCLUSIONS

Midlife CVRFs, especially hypertension, diabetes mellitus, and smoking, are common and associated with accelerated cognitive decline at midlife. These results identify potential modifiable targets to prevent midlife cognitive decline and highlight the need for a life course approach to cognitive function and aging.

Medical and non-medical marijuana use in depression: Longitudinal associations with suicidal ideation, everyday functioning, and psychiatry service utilization

BACKGROUND

Marijuana use is clinically problematic in depression, and non-medical and medical use may both contribute to barriers to care in this population. Among outpatients with depression, we examined the differential impact of medical or non-medical marijuana use, relative to no-use, on psychopathology and service use over time.

METHOD

Participants were 307 psychiatry outpatients participating in a trial of drug/alcohol use treatment for depression. Measures of past 30-day marijuana use, depression/anxiety symptoms, psychiatry visits, and functional data related to health status were collected at baseline, 3, 6, and 12 months. Regressions (baseline and 1 year) and growth models (over time) predicted clinical and psychiatry visit outcomes, from medical or non-medical marijuana use (no-use = reference).

RESULTS

At baseline, 40.0% of the sample used marijuana and more reported non-medical (71.7%) than medical (28.2%) use. Relative to non-users at baseline, patients using medically had worse mental/physical health functioning (p's < 0.05), and non-medical use was associated with higher suicidal ideation (B = 1.08, p = .002), worse mental health functioning (B = -3.79, p = .015), and fewer psychiatry visits (B = -0.69, p = .009). Patients using non-medically over time improved less in depression symptoms (B = 1.49, p = .026) and suicidal ideation (B = 1.08, p = .003) than non-users.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Marijuana use, especially non-medical use, among patients with depression may impede depression symptom improvement while lessening the likelihood of psychiatry visits. Marijuana use and associated barriers to care should receive consideration by depression treatment providers.

Adverse impact of marijuana use on clinical outcomes among psychiatry patients with depression and alcohol use disorder

This study examined whether marijuana use was associated with clinically problematic outcomes for patients with depression and alcohol use disorder (AUD). The sample consisted of 307 psychiatry outpatients with mild to severe depression and past 30-day hazardous drinking/drug use, who participated in a trial of substance use treatment. Participants were assessed for AUD based on DSM-IV criteria. Measures of marijuana use, depression symptoms, and functional status related to mental health were collected at baseline, 3, and 6 months. Differences in these outcomes were analyzed among patients with and without AUD using growth models, adjusting for treatment effects. Marijuana was examined as both an outcome (patterns of use) and a predictor (impact on depression and functioning). Forty percent used marijuana and about half the sample met AUD criteria. Fewer patients with AUD used marijuana than those without AUD at baseline. Over 6 months, the proportion of patients with AUD using marijuana increased compared to those without AUD. Patients with AUD using marijuana had greater depressive symptoms and worse functioning than those without AUD. These findings indicate that marijuana use is clinically problematic for psychiatry outpatients with depression and AUD. Addressing marijuana in the context of psychiatry treatment may help improve outcomes.

Alcohol and Drug Use, Pain and Psychiatric Symptoms among Adults Seeking Outpatient Psychiatric Treatment: Latent Class Patterns and Relationship to Health Status

BACKGROUND

Substance use, psychiatric problems, and pain frequently co-occur, yet clinical profiles of treatment-seeking patients are poorly understood. To inform service and treatment planning, substance use and symptom patterns were examined in an outpatient psychiatry clinic, along with the relationship of these patterns to demographic characteristics and physical health.

METHODS

Patients (N = 405; age M = 38; 69% White; 60% female) presenting for intake in a psychiatry outpatient clinic completed a computerized assessment of psychiatric problems, drinking, and drug use. Substance use and psychiatric symptom patterns among the sample were identified using latent class analysis.

RESULTS

A 4-class model fit the data best: Class (1) Moderate symptoms/wide-range users (22.0%) had moderate depression and panic; tobacco, cocaine, hallucinogen, and ecstasy use; and high cannabis use. Class (2) Moderate depression/panic (37.8%) had moderate depression and panic. Class (3) Depression/anxiety, tobacco, and cannabis users (28.0%) had high depression, obsessions, and panic, and moderate pain severity, social phobia, compulsions, trauma, tobacco, and cannabis use. Class (4) Severe/wide range symptoms/users (12.0%) had high panic, depression, social phobia, obsessions, drug use, and moderate pain. Gender, ethnicity, and health status varied by class.

CONCLUSIONS

Findings highlight the preponderance of substance use (particularly cannabis) and its relationship to psychiatric symptom severity, pain, and health status among those presenting for mental health treatment.

Alcohol, marijuana, and opioid use disorders: 5-Year patterns and characteristics of emergency department encounters

BACKGROUND

Changes in substance use patterns stemming from opioid misuse, ongoing drinking problems, and marijuana legalization may result in new populations of patients with substance use disorders (SUDs) using emergency department (ED) resources. This study examined ED admission trends in a large sample of patients with alcohol, marijuana, and opioid use disorders in an integrated health system.

METHODS

In a retrospective design, electronic health record (EHR) data identified patients with ≥1 of 3 common SUDs in 2010 (n = 17,574; alcohol, marijuana, or opioid use disorder) and patients without SUD (n = 17,574). Logistic regressions determined odds of ED use between patients with SUD versus controls (2010-2014); mixed-effect models examined 5-year differences in utilization; moderator models identified subsamples for which patients with SUD may have a greater impact on ED resources.

RESULTS

Odds of ED use were higher at each time point (2010-2014) for patients with alcohol (odds ratio [OR] range: 5.31-2.13, Ps < .001), marijuana (OR range: 5.45-1.97, Ps < .001), and opioid (OR range: 7.63-4.19, Ps < .001) use disorders compared with controls; odds decreased over time (Ps < .001). Patients with opioid use disorder were at risk of high ED utilization; patients were 7.63 times more likely to have an ED visit in 2010 compared with controls and remained 5.00 (average) times more likely to use ED services. ED use increased at greater rates for patients with alcohol and opioid use disorders with medical comorbidities relative to controls (Ps < .045).

CONCLUSIONS

ED use is frequent in patients with SUDs who have access to private insurance coverage and integrated medical services. ED settings provide important opportunities in health systems to identify patients with SUDs, particularly patients with opioid use disorder, to initiate treatment and facilitate ongoing care, which may be effective for reducing excess medical emergencies and ED encounters.

Serious mental illness and medical comorbidities: Findings from an integrated health care system

OBJECTIVE

To examine the odds associated with having medical comorbidities among patients with serious mental illness (SMI) in a large integrated health system.

METHOD

In a secondary analysis of electronic health record data, this study identified 25,090 patients with an ICD-9 SMI diagnosis of bipolar disorder (n=20,308) or schizophrenia (n=4782) and 25,090 controls who did not have a SMI, matched on age, gender, and medical home facility. Conditional logistic regressions compared the odds associated with having nine medical comorbidity categories and fifteen chronic or serious conditions among patients with SMI versus controls.

RESULTS

Results showed having a SMI was associated with significantly higher odds of each medical comorbidity examined (p's<0.001), except no evidence of a significant association was found between having schizophrenia and musculoskeletal diseases. A similar pattern was found regarding the chronic or severe conditions, where having schizophrenia or bipolar was associated with >1.5 times the odds of each condition (p's<0.001).

CONCLUSIONS

In an integrated health system where patients may have fewer barriers to care, SMI patients are likely to present for treatment with a range of medical comorbidities, including chronic and severe conditions. SMI patients may need outreach strategies focused on disease prevention, screening and early diagnosis, and treatment to address medical comorbidities and associated poor health outcomes.

Prescription opioid registry protocol in an integrated health system

OBJECTIVES

To establish a prescription opioid registry protocol in a large health system and to describe algorithms to characterize individuals using prescription opioids, opioid use episodes, and concurrent use of sedative/hypnotics.

STUDY DESIGN

Protocol development and retrospective cohort study.

METHODS

Using Kaiser Permanente Northern California (KPNC) electronic health record data, we selected patients using prescription opioids in 2011. Opioid and sedative/hypnotic fills, and physical and psychiatric comorbidity diagnoses, were extracted for years 2008 to 2014. Algorithms were developed to identify each patient's daily opioid and sedative/hypnotic use, and morphine daily-dose equivalent. Opioid episodes were classified as long-term, episodic, or acute. Logistic regression was used to predict characteristics associated with becoming a long-term opioid user.

RESULTS

In 2011, 18% of KPNC adult members filled at least 1 opioid prescription. Among those patients, 25% used opioids long term and their average duration of use was more than 4 years. Sedative/hypnotics were used by 76% of long-term users. Being older, white, living in a more deprived neighborhood, having a chronic pain diagnosis, and use of sedative/hypnotics were predictors of initiating long-term opioid use.

CONCLUSIONS

This study established a population-based opioid registry that is flexible and can be used to address important questions of prescription opioid use. It will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.

Patterns of marijuana use among psychiatry patients with depression and its impact on recovery

BACKGROUND

Depression is associated with substance-related problems that worsen depression-related disability. Marijuana is frequently used by those with depression, yet whether its use contributes to significant barriers to recovery in this population has been understudied.

METHOD

Participants were 307 psychiatry outpatients with depression; assessed at baseline, 3-, and 6-months on symptom (PHQ-9 and GAD-7), functioning (SF-12) and past-month marijuana use for a substance use intervention trial. Longitudinal growth models examined patterns and predictors of marijuana use and its impact on symptom and functional outcomes.

RESULTS

A considerable number of (40.7%; n=125) patients used marijuana within 30-days of baseline. Over 6-months, marijuana use decreased (B=-1.20, p<.001), but patterns varied by demographic and clinical characteristics. Depression (B=0.03, p<.001) symptoms contributed to increased marijuana use over the follow-up, and those aged 50+(B=0.44, p<.001) increased their marijuana use compared to the youngest age group. Marijuana use worsened depression (B=1.24, p<.001) and anxiety (B=0.80, p=.025) symptoms; marijuana use led to poorer mental health (B=-2.03, p=.010) functioning. Medical marijuana (26.8%; n=33) was associated with poorer physical health (B=-3.35, p=.044) functioning.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Marijuana use is common and associated with poor recovery among psychiatry outpatients with depression. Assessing for marijuana use and considering its use in light of its impact on depression recovery may help improve outcomes.

The role of hazardous drinking reductions in predicting depression and anxiety symptom improvement among psychiatry patients: A longitudinal study

BACKGROUND

Co-occurrence of depression, anxiety, and hazardous drinking is high in clinical samples. Hazardous drinking can worsen depression and anxiety symptoms (and vice versa), yet less is known about whether reductions in hazardous drinking improve symptom outcomes.

METHODS

Three hundred and seven psychiatry outpatients were interviewed (baseline, 3-, 6-months) for hazardous drinking (drinking over recommended daily limits), depression (PHQ-9), and anxiety (GAD-7) as part of a hazardous drinking intervention trial. Longitudinal growth models tested associations between hazardous drinking and symptoms (and reciprocal effects between symptoms and hazardous drinking), adjusting for treatment effects.

RESULTS

At baseline, participants had moderate anxiety (M=10.81; SD=10.82) and depressive symptoms (M=13.91; SD=5.58); 60.0% consumed alcohol at hazardous drinking levels. Over 6-months, participants' anxiety (B=-3.03, p<.001) and depressive symptoms (B=-5.39, p<.001) improved. Continued hazardous drinking led to slower anxiety (B=0.09, p=.005) and depressive symptom (B=0.10, p=.004) improvement; reductions in hazardous drinking led to faster anxiety (B=-0.09, p=.010) and depressive (B=-0.10, p=.015) symptom improvement. Neither anxiety (B=0.07, p=.066) nor depressive (B=0.05, p=.071) symptoms were associated with hazardous drinking outcomes.

LIMITATIONS

Participants were psychiatry outpatients, limiting generalizability.

CONCLUSIONS

Reducing hazardous drinking can improve depression and anxiety symptoms but continued hazardous use slows recovery for psychiatry patients. Hazardous drinking-focused interventions may be helpful in promoting symptom improvement in clinical populations.

Cognitive enhancement therapy for adults with autism spectrum disorder: results of an 18-month feasibility study

Adults with autism experience significant impairments in social and non-social information processing for which few treatments have been developed. This study conducted an 18-month uncontrolled trial of Cognitive Enhancement Therapy (CET), a comprehensive cognitive rehabilitation intervention, in 14 verbal adults with autism spectrum disorder to investigate its feasibility, acceptability, and initial efficacy in treating these impairments. Results indicated that CET was satisfying to participants, with high treatment attendance and retention. Effects on cognitive deficits and social behavior were also large (d = 1.40-2.29) and statistically significant (all p < .001). These findings suggest that CET is a feasible, acceptable, and potentially effective intervention for remediating the social and non-social cognitive impairments in verbal adults with autism.

Neurocognitive functioning of individuals with schizophrenia: using and not using drugs

OBJECTIVES

Research on neurocognition in schizophrenia, using modest samples and self-rated assessments, reports drug use contributes to improved rather than impaired cognitive function. We have sought to replicate these findings in a large sample of patients that had their drug-use status confirmed by laboratory assays and evaluated the potential differences in cognitive function between patients with positive and negative results.

METHODS

Nine hundred and seventy four schizophrenia patients completed neuropsychological and laboratory tests at screening/baseline of the Clinical Antipsychotic Trials of Intervention Effectiveness study. Radioimmunoassay (RIA) of hair tested for cannabis, cocaine and methamphetamine.

RESULTS

Many patients screened positive for drug use (n = 262; 27%), and there were no differences between patients with positive and negative results in terms of cognitive function after adjusting for multiple inference testing, except patients with positive RIA for methamphetamine demonstrated increased processing speed (corrected, P = .024). Moderator models were employed to explore potential subgroup differences in this pattern of results. At low medication dosages, patients with positive RIA for cocaine demonstrated decreased processing speed compared with patients with negative RIA for cocaine (uncorrected, P = .008). And for any other drugs with low psychopathology, patients with positive RIA demonstrated decreased working memory compared with patients with negative RIA (uncorrected, P = .006).

CONCLUSIONS

No positive effects of cannabis on cognitive function were observed, and drug use was not associated with improved neurocognition across most of the subgroup characteristics explored in this sample of schizophrenia patients.

Under-reporting of drug use among individuals with schizophrenia: prevalence and predictors

BACKGROUND

Illicit drug use is common in individuals with schizophrenia, and it has been suspected that many individuals under-report their use of substances, leading to significant barriers to treatment. This study sought to examine the degree to which individuals with schizophrenia disclose their use of drugs on self-rated assessments, compared to laboratory assays, and to determine the contributors of under-reported drug use in this population.

METHOD

A total of 1042 individuals with schizophrenia who participated in screening/baseline procedures for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) completed self-rated assessments of substance use and laboratory drug testing. Laboratory tests assayed cannabis, cocaine and methamphetamine use; the procedures included radioimmunoassay (RIA) and urine drug screens.

RESULTS

A significant proportion of participants tested positive for drug use on laboratory measures (n = 397; 38%), and more than half (n = 229; 58%) did not report using these drugs. Logistic regression models confirmed that patients who were most likely to conceal their use tended to be older, and presented with greater neurocognitive deficits. Patients who accurately reported drug use tended to have greater involvement with the criminal justice system. Illness severity and psychopathology were not associated with whether patients disclosed drug use.

CONCLUSIONS

Rates of under-reported drug use are considerable among individuals with schizophrenia when compared to laboratory assays, and the exclusive reliance on self-rated assessments should be used with caution. Patients who under-report their drug use are more likely to manifest neurocognitive deficits, which could be improved by interventions attempting to optimize treatment.

Characterizing the longitudinal patterns of substance use among individuals diagnosed with serious mental illness after psychiatric hospitalization

AIM

To characterize longitudinal patterns of substance use across a large sample of psychiatric patients discharged from inpatient admission, followed for 1-year post-hospitalization.

DESIGN

Prospective cohort study.

SETTING

Kansas City, MO, USA; Pittsburgh, PA, USA; Worcester, MA, USA.

PARTICIPANTS

Eight hundred and one schizophrenia-spectrum (n = 204), bipolar (n = 137) and depressive disorder (n = 460) patients from the MacArthur Violence Risk Assessment Study.

MEASUREMENTS

Symptoms, functioning, drug/alcohol use assessed by the Brief Psychiatric Rating Scale, the Global Assessment of Functioning, and substance use interviews.

FINDINGS

Patients used alcohol (67.0%; n = 540) and cannabis (30.0%; n = 237) more frequently than other substances up to 30 days before admission, and those with depressive and schizophrenia-spectrum used heroin more than individuals with bipolar (P = 0.023). Post-hospitalization, patients using alcohol (B = -0.15, P < 0.001) and cannabis (B = -0.27, P < 0.001) decreased, but patterns varied across diagnosis and genders. Patients using cannabis decreased at greater rates in depressive and schizophrenia-spectrum compared with bipolar (all P < 0.05), and more men used alcohol (B = 0.76, P < 0.001) and cannabis (B = 1.56, P < 0.001) than women. Cannabis (B = 1.65, P < 0.001) and alcohol (B = 1.04, P = 0.002) were associated with higher symptomatology; cannabis (B = -2.33, P < 0.001) and alcohol (B = -1.45, P = 0.012) were associated with lower functioning.

CONCLUSIONS

Substance use is frequent and associated with poor recovery in patients with serious mental illness recently discharged from psychiatric hospitalization. Addiction treatments personalized by diagnosis and gender may be effective for improving outcomes in people with serious mental illness.

Interviewer-perceived honesty as a mediator of racial disparities in the diagnosis of schizophrenia

OBJECTIVE

African Americans are disproportionately diagnosed as having schizophrenia, and the factors that contribute to this disparity are poorly understood. This study utilized data from the 1995 MacArthur Violence Risk Assessment Study to examine the impact of racial differences in sociodemographic characteristics, clinical presentation, and perceived honesty on disparities in the diagnosis of schizophrenia among African Americans.

METHODS

Researchers using structured assessments of diagnostic, sociodemographic, and clinical measures interviewed African Americans (N=215) and whites (N=537) receiving inpatient care for a severe mental illness. The impact of interviewers' perceptions of the participants' honesty on racial disparities in the diagnosis of schizophrenia was assessed.

RESULTS

African Americans (45%) were more than three times as likely as whites (19%) to be diagnosed as having schizophrenia. Disparities in sociodemographic and clinical characteristics modestly contributed to disparities in diagnostic rates. In contrast, interviewer-perceived honesty proved to be a significant predictor of racial disparities in schizophrenia diagnoses. After adjustment for perceived honesty, diagnostic disparities between African Americans and whites were substantially reduced. Mediator analyses confirmed that interviewer-perceived honesty was the only consistent mediator of the relationship between race and schizophrenia diagnosis.

CONCLUSIONS

Interviewers' perceptions of honesty among African-American participants are important contributors to disparities in the diagnosis of schizophrenia. Clinicians' perceptions of dishonesty among African-American patients may reflect poor patient-clinician relationships. Methods of facilitating a trusting relationship between patients and clinicians are needed to improve the assessment and treatment of persons from minority groups who are seeking mental health care. (Psychiatric Services 63:875-880, 2012; doi: 10.1176/appi.ps.201100388).

Examining the course and outcome of individuals diagnosed with schizophrenia and comorbid borderline personality disorder

This research examined the prevalence of comorbid borderline personality disorder (BPD) in a sample of schizophrenia inpatients, and then investigated the degree to which BPD comorbidity impacted symptom and functional outcomes after 1-year post-hospital discharge. A sample of 142 individuals with a diagnosis of schizophrenia (n = 100) or schizoaffective disorder (n = 42) from the MacArthur Violence Risk Assessment Study were administered the Structured Interview for DSM-III-R Personality (SIDP-R). Symptom and functional outcome data were gathered during hospitalization and at 1-year follow-up to analyze differences in symptom and functioning characteristics between those diagnosed with and without BPD. Results indicated that comorbid BPD was present in a non-trivial proportion (17.6%, n = 25) of the sample, based on SIDP-R assessment. Baseline analyses indicated that patients with BPD presented with modest elevations in the severity of overall psychiatric symptomatology, and higher levels of anxiety and depression, at hospitalization compared to non-BPD patients. At 1-year follow-up, results revealed that after adjusting for baseline differences, patients with schizophrenia and comorbid BPD showed significantly less improvement in psychiatric symptomatology, particularly hostility and suspiciousness, as well as global functioning, and were re-hospitalized at significantly higher rates than patients without BPD. Our findings indicate that the co-occurrence of schizophrenia and BPD is not infrequent and that BPD has a significant negative longitudinal impact on the course and outcome of patients with schizophrenia.