WAIT, WON'T! WANT: BARRIERS TO HEALTH CARE AS PERCEIVED BY MEDICALLY AND SOCIALLY DISENFRANCHISED COMMUNITIES.

OBJECTIVES: We explored barriers to healthcare as perceived by members of medically and socially disenfranchised communities. METHODS: We conducted focus groups with 28 women and 32 men from Northeast Ohio who identified themselves as African-American, Hispanic/Latino, lesbian/gay/bisexual/transgendered, and/or Russian immigrant. RESULTS: Participants described their experiences of waiting, things they won't tolerate, when they won't participate, and what they want from providers. They described behaviors, actions and relationship characteristics that they want from their providers and characteristics that they prefer in health systems. CONCLUSIONS: The themes of Wait, Won't, and Want have healthcare practice and policy implications. Patient-provider interactions are known to be significant determinants of healthcare outcomes and these exploratory findings suggest that they might also affect patient self-management strategies. Future efforts should focus on developing and testing patient-centered strategies that address the themes identified to increase engagement to increase self-management of health.

A qualitative investigation of self-stigma among adolescents taking psychiatric medication.

OBJECTIVE: The extant literature describes stigma in two forms, public stigma and self-stigma. Public stigma pertains to negative social behaviors, reactions, attitudes, and beliefs directed toward people with mental illness and among persons with mental illness. Self-stigma concerns the internalized effects of public stigma. Although both types of stigma have negative impacts on people with mental illness, they produce different effects. In particular, self-stigma can negatively affect self-esteem, social relationships, willingness to engage in life opportunities, and adherence to psychiatric services. Few adult stigma models represent self-stigma, and no models exist that examine self-stigma among adolescents with a mental illness. Because of developmental differences, adolescent self-stigma may be distinct from that of adults. This study aimed to develop a self-stigma model to elucidate youths' responses to mental illness labels and how psychiatric services affect self-image and self-efficacy. METHODS: The qualitative study included a sample of 27 adolescents between the ages of 12 and 17 who took psychiatric medication for a mental illness diagnosis. A semistructured interview, the Teen Subjective Experience Medication Interview, was used to query adolescents about their perceptions of having a psychiatric diagnosis and of taking psychiatric medication. The analytic strategy identified a sequence of narrative plot components that illustrated a self-stigma process among adolescents. RESULTS: The findings revealed a self-stigma model comprising three narrative components: stereotype, differentiate, and protect. CONCLUSIONS: The adolescent model was similar to yet distinct from the adult model, and developmental differences may contribute to the variation. The need for future research to validate an adolescent self-stigma model is discussed.

Social Support: A Mixed Blessing for Women in Substance Abuse Treatment.

Using a personal social network framework, this qualitative study sought to understand how women in substance abuse treatment describe their network members' supportive and unsupportive behaviors related to recovery. Eighty-six women were interviewed from residential and outpatient substance abuse treatment programs. Positive and negative aspects of women's social networks were assessed via open-ended questions. Analysis was guided by grounded theory techniques using three coders. The findings extend classic social support concepts such as emotional, tangible, and informational support. Practice implications are presented in light of the potential roles network members may play in substance use and recovery.

Desire and disappointment: adolescent psychotropic treatment and adherence.

This paper situates medication adherence among adolescents in current cultural and political-economic debates about compliance/adherence and the formation of biomedical subjectivities. Building on prior work of the authors, this paper explores the role of desire in adherence to show how subjectivities are shaped by concordant, instrumental, or conditional forms of desire. Data is used to show how parents and adolescents compare the medicated self before and after, resulting in the formation of desire. It is argued that adherence is an outcome of desire: no desire, no adherence, or varying types of desire. Moreover, adherence is not a steady state. It is produced moment to moment as adolescents confront the desires of others. The study uses interview data to construct a case study of concordant desire, which is a form most likely to produce adherence. With concordant desire the medicated come to expect a future life on medication and a life where symptoms are stripped of their social and psychological meaning and significance.

Are health beliefs related to adherence among adolescents with mood disorders?

This study explored the illness perceptions, attitudes towards mental health services and adherence behaviors among a group of adolescents in treatment for mood disorders in an urban city in the United States. Seventy adolescents completed a battery of questionnaires assessing demographics (e.g., gender, family income), perceptions of illness (e.g., consequences, treatment control) and overall attitudes towards mental health services. Adolescents and their parents also reported on the youth's adherence to both psychotropic medication and mental health appointments. Simultaneous logistic regression analyses revealed that attitudes and family income made a significant and unique contribution in explaining adolescents' adherence behaviors. Interventions that help adolescents become aware of their attitudes toward mental health services and provide information on dimensions of mood disorders, such as the chronic nature of depression and the effectiveness of treatment, may impact adherence behavior. Also, among a group of families with access to services, yearly family income remained a significant barrier to attending appointments all of the time. Policy implications are discussed.

Attitudes Toward Mental Health Services and Illness Perceptions Among Adolescents with Mood Disorders.

The present study describes how adolescents perceive their mood disorders (MD; e.g., acute vs. chronic) and their attitudes toward mental health services. The study also explores the relationships between demographics, clinical characteristics, perceptions of illness and attitudes. Finally, we examine the psychometric properties of the Illness Perception Questionnaire-Revised (Moss-Morris et al. in Psychology & Health 17(1):1-16, 2002). Seventy adolescents were recruited from the greater Cleveland area. Structured interviews were conducted utilizing standardized instruments. Results show that adolescents with MD have fairly positive attitudes, with Caucasian youth reporting more positive attitudes than their nonwhite ounterparts. Illness perceptions were related to psychological openness and indifference to stigma. Implications are discussed.

Adolescent attitudes toward psychiatric medication: the utility of the Drug Attitude Inventory.

BACKGROUND: Despite the effectiveness of psychotropic treatment for alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adolescent adherence rates range from 10-80% (Swanson, 2003; Cromer & Tarnowski, 1989; Lloyd et al., 1998; Brown, Borden, and Clingerman, 1985; Sleator, 1985) depending on the population and medication studied. Youth with serious mental illness face increased potential for substance abuse, legal problems, suicide attempts, and completed suicide (Birmaher & Axelson, 2006). Nonadherence may increase the potential for negative outcomes. The Drug Attitude Inventory (DAI) was created to measure attitudes toward neuroleptics and to predict adherence in adults (Hogan, Awad, & Eastwood, 1983). No studies have been identified that have used this instrument in adolescent psychiatric populations. The present study was undertaken to evaluate the utility of the DAI for measuring medication attitudes and predicting adherence in adolescents diagnosed with mental health disorders. METHOD: Structural equation modeling was used to compare the factor structure of the DAI in adults with its factor structure in adolescents. The relationship between adolescent DAI scores and adherence was examined also. RESULTS: The adult factor structure demonstrated only "fair" fit to the adolescent data (RMSEA = .061). Results indicated a low, but significant positive correlation (r = .205, p < .05) between DAI scores and adherence. CONCLUSIONS: Lack of optimal model fit suggests that DAI items may require alteration to reflect adolescent experiences with psychiatric medication more accurately. Differences between adolescents and adults in developmental stage, symptom chronicity, diagnosis, and medication class may explain why the adult model demonstrated only "fair fit" to the adolescent data and why the correlation between DAI scores and adherence was low. The DAI may be improved for use with adolescents by creating items reflecting autonomy concerns, diagnostic characteristics, treatment length, and side effect profiles relevant to adolescent experiences.

Adolescent experience of psychotropic treatment.

Despite growing concern over the treatment of adolescents with psychiatric medications, little research has examined youth understandings and interpretations of mental illness and psychotropic treatment. This article reports the exploratory findings of semi-structured and open-ended interviews carried out with 20 adolescents diagnosed with one or more psychiatric disorders, and who were currently prescribed psychiatric medications. Grounded theory coding procedures were used to identify themes related to adolescent subjective experience with psychiatric medications. The categories identified are interpreted as different points of view through which adolescents understand and take action upon their illness concerns; their need for medication treatment; their perceptions of how medications work; their responses to parental and other influences upon medication treatment; and, their everyday management activities.

Subjective experience of recovery from schizophrenia-related disorders and atypical antipsychotics.

AIMS: This article investigates the subjective experience of the process of improvement and recovery from the point of view of persons diagnosed (according to research diagnostic criteria) with schizophrenia and schizo-affective disorders. METHODS: A community study of persons using psychiatric services was conducted for a sample of ninety subjects taking atypical antipsychotic medications. Sociodemographic data and clinical ratings were collected to complement the qualitatively developed Subjective Experience of Medication Interview (SEMI), which elicits narrative data on everyday activities, medication and treatment, management of symptoms, expectations concerning recovery, stigma, and quality of life. RESULTS: Recovery was observed through: (1) relatively low ratings of psychiatrically observed symptomatology through BPRS scores; (2) the subjective sense among the majority (77.4%) of participants that taking medication plays a critical role in managing symptoms and avoiding hospitalization; and (3) the subjective sense articulated by the vast majority (80%) that they would recover from their illness and that the quality of their lives would improve (70.6%). CONCLUSION: The overall quality of improvement and recovery is best characterized as an incremental, yet definitively discernable, subjective process.

The Subjective Experience of Youth Psychotropic Treatment.

The psychotropic treatment of youth is increasing dramatically. This article examines child and adolescent psychopharmacological research and argues that social work practice and research must examine the complex relationships, social and psychological, in youth pharmacologic treatment. Regarding identity formation, this article explores the developmental consequences when youth adopt an illness narrative to make sense of everyday medication treatment. A conceptual framework for mapping the socio-cultural context of youth medication management is outlined. In the conclusion, youth psychotropic treatment is connected to a perplexing 'interpretive gap,' which highlights the subjective quality of medication treatment.

The social grid of community medication management.

Practitioners involved in case management at a community mental health center organized 5 elements of a psychotropic medication experience. Using case records, interview, and observational data, the authors examined an underresearched and especially problematic area of the management process: the interpretation of a medication's effect. They describe the divisions of labor, a grid of social relations, and spaces related to management, and they describe how the limits and potential of medications are realized in the intensity of monitoring and the knowledge produced in the day-to-day practices among all participants.