Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities?

Researchers have repeatedly observed that clinicians diagnose Black individuals with schizophrenia at greater rates than White individuals. We conducted a meta-analytic review to quantify the extent of racial diagnostic disparities in schizophrenia, examine whether structured-interview assessments attenuate these disparities, and assess for moderating factors. Studies were included that presented original probability-sample data and reported data sufficient to derive odds ratios and 95% confidence intervals (CIs) for schizophrenia diagnosis by race. In total, 14 studies using structured-interview diagnostic assessments and 41 studies using unstructured assessments met our inclusion criteria. Substantial heterogeneity was observed, but there was little evidence of publication bias. Inverse heterogeneity models showed that Black individuals were diagnosed with schizophrenia at greater rates than White individuals across all studies (OR = 2.42, 95% CI [1.59, 3.66]) as well as in studies using unstructured (OR = 2.43, 95% CI [1.59, 3.72]) and structured-instrument (OR = 1.77, 95% CI [1.31, 2.38]) diagnostic assessments. Studies using structured-instrument diagnostic assessments did not show statistically attenuated odds ratios compared with studies using unstructured assessments. Metaregression analyses indicated higher disparities in studies with higher proportions of White patients or lower average patient age; evidence was equivocal as to the effect of study setting (e.g., hospital vs. community clinic) and geographic region on racial disparities. Overall, racial diagnostic disparity in schizophrenia represents a robust albeit heterogeneous clinical phenomenon that has been stable over the past 3 decades; structured-instrument assessments do not fully mitigate these disparities, but power analysis suggests they may have a small effect. (PsycINFO Database Record

Assessment of attachment in psychosis: A psychometric cause for concern.

Attachment has recently been proposed as a key developmental construct in psychosis, in particular with respect to interpersonal functioning and social cognition. The current study examined the latent structure of the self-report Psychosis Attachment Measure (PAM) and its relationship to lower-level perceptual and higher-order inferential social cognitive processes. The PAM was administered to 138 psychiatrically stable outpatients with schizophrenia alongside a battery of symptom, social cognitive, and functional measures. PAM responses were analyzed using latent variable measurement models, which did not yield evidence of the coherent two-dimensional structure predicted by previous literature. A unidimensional subscale comprising 6 of the 16 original PAM items possessed the strongest psychometric properties. This subscale was generally uncorrelated with social cognitive measures and showed weak correlations with some symptoms measures and with community functioning. These results suggest that either the PAM may not measure attachment in psychosis or it may measure only attachment anxiety but demonstrate little construct validity in this population. These results tell a cautionary tale regarding making theoretical inferences on the basis of measures without coherent latent structure. Attachment measures with stronger psychometric properties will help clarify putative relationships between attachment and social cognitive processes in psychosis.

Treatment outcome variation between depression symptom combinations in the STAR*D study.

BACKGROUND: In response to recent documentation of symptom and subtype heterogeneity in major depressive disorder, we report on exploratory analyses of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) clinical-trial data to further describe heterogeneity in depression and test the hypothesis that citalopram treatment-outcome patterns differ as a function of depression symptom combinations. METHODS: Combinatorial algorithms, latent profile analysis, and repeated-measures multivariate analysis of variance were employed to characterize heterogeneity and depression outcome-measure profile variability in the most prevalent symptom combinations with full data (26% of baseline and 13% of endpoint total sample). RESULTS: Descriptive results suggest that substantial heterogeneity and moderate coherence characterize major depressive disorder; as in previous analyses, pairs of individuals sharing no symptoms in common were observed. Exploratory latent profile analysis indicated that different patterns of treatment outcome data exist among STAR*D participants. A small but significant interaction effect of symptom combination×outcome measure profile was observed for clinician-rated but not self-reported symptom combinations. LIMITATIONS: Factors moderating the generalizability of these findings include binary symptom measures, a short treatment period, and a smaller number of individuals per combination. CONCLUSIONS: These results provide evidence that citalopram treatment outcomes vary as a function of diagnostic combinations, thereby providing preliminary evidence that the substantial heterogeneity documented in depression symptom presentations may carry implications for prognosis and treatment outcome. At the level of descriptive phenomenology, these results appear to corroborate the claim that depression is not a homogenous syndrome.

Self-reported comfort treating severe mental illnesses among pre-doctoral graduate students in clinical psychology.

BACKGROUND: One possible explanation for the dearth of psychologists working in severe mental illness (SMI) areas is a lack of training opportunities. Recent studies have shown that while training opportunities have increased, there remain fewer resources available for SMI training compared to other disorders. AIM: Examines whether students express discomfort working with this population and whether they are satisfied with their level of training in SMI. METHODS: One-hundred sixty-nine students currently enrolled in doctoral programs in clinical psychology in the United States and Canada were surveyed for their comfort treating and satisfaction with training related to a number of disorders. RESULTS: RESULTS indicate that students are significantly less comfortable treating and finding a referral for a patient with schizophrenia as well as dissatisfied with their current training in SMI and desirous of more training. Regression analyses showed that dissatisfaction with training predicted a desire for more training; however, discomfort in treating people with SMI did not predict a desire for more training in this sample. This pattern generally held across disorders. CONCLUSIONS: Our results suggest general discomfort among students surveyed in treating SMI compared to other disorders.

Quantifying heterogeneity attributable to polythetic diagnostic criteria: theoretical framework and empirical application.

Heterogeneity within psychiatric disorders is both theoretically and practically problematic: For many disorders, it is possible for 2 individuals to share very few or even no symptoms in common yet share the same diagnosis. Polythetic diagnostic criteria have long been recognized to contribute to this heterogeneity, yet no unified theoretical understanding of the coherence of symptom criteria sets currently exists. A general framework for analyzing the logical and mathematical structure, coherence, and diversity of Diagnostic and Statistical Manual diagnostic categories (DSM-5 and DSM-IV-TR) is proposed, drawing from combinatorial mathematics, set theory, and information theory. Theoretical application of this framework to 18 diagnostic categories indicates that in most categories, 2 individuals with the same diagnosis may share no symptoms in common, and that any 2 theoretically possible symptom combinations will share on average less than half their symptoms. Application of this framework to 2 large empirical datasets indicates that patients who meet symptom criteria for major depressive disorder and posttraumatic stress disorder tend to share approximately three-fifths of symptoms in common. For both disorders in each of the datasets, pairs of individuals who shared no common symptoms were observed. Any 2 individuals with either diagnosis were unlikely to exhibit identical symptomatology. The theoretical and empirical results stemming from this approach have substantive implications for etiological research into, and measurement of, psychiatric disorders.

Adapting social neuroscience measures for schizophrenia clinical trials, part 3: fathoming external validity.

It is unknown whether measures adapted from social neuroscience linked to specific neural systems will demonstrate relationships to external variables. Four paradigms adapted from social neuroscience were administered to 173 clinically stable outpatients with schizophrenia to determine their relationships to functionally meaningful variables and to investigate their incremental validity beyond standard measures of social and nonsocial cognition. The 4 paradigms included 2 that assess perception of nonverbal social and action cues (basic biological motion and emotion in biological motion) and 2 that involve higher level inferences about self and others' mental states (self-referential memory and empathic accuracy). Overall, social neuroscience paradigms showed significant relationships to functional capacity but weak relationships to community functioning; the paradigms also showed weak correlations to clinical symptoms. Evidence for incremental validity beyond standard measures of social and nonsocial cognition was mixed with additional predictive power shown for functional capacity but not community functioning. Of the newly adapted paradigms, the empathic accuracy task had the broadest external validity. These results underscore the difficulty of translating developments from neuroscience into clinically useful tasks with functional significance.