Factors associated with medication adherence in African American and white patients with bipolar disorder.

BACKGROUND: African American patients may be less likely than white patients to adhere to maintenance pharmacotherapy for bipolar disorder. The purpose of this study was to examine rates of medication nonadherence, self-perceived reasons for nonadherence, and attitudes associated with non-adherence in these ethnic groups. METHOD: 20 African American and 30 white subjects with DSM-IV bipolar I disorder participated in this study. At a single follow-up visit with patients at least 4 months after their first hospitalization for acute mania, we assessed demographics, symptom severity, degrees of adherence, reasons for non-adherence, and self-perceptions regarding factors previously associated with nonadherence using a visual analog scale (VAS). The cross-sectional data that are the subject of this report were obtained from July 1, 2002, through June 30, 2004. RESULTS: Over 50% of participants in each group were currently either fully or partially nonadherent with medications. Greater than 20% of participants in each group denied having bipolar disorder and described physical side effects from medications as contributing to nonadherence. In principal components analysis of the VAS, 2 components were identified. The first component contained patient-related factors associated with nonadherence, while the second contained a combination of illness- and medication-related factors. African American participants were more likely to endorse patient-related factors associated with nonadherence relative to white participants. Specifically, African Americans self-endorsed a fear of becoming addicted to medications and feeling that medications were symbols of mental illness. CONCLUSION: Findings suggest that both African American and white patients with bipolar disorder demonstrate poor medication adherence that they attribute to illness/medication-related factors (denial of illness, physical side effects). However, patient-related factors (fear of addiction, medication as a symbol of illness) accounted for ethnic differences on self-perceived ratings of nonadherence factors. Differences in the reasons for nonadherence relative to culturally biased self-perceptions may help explain nonadherence behaviors in the African American community.

Sex, ethnicity, and antipsychotic medication use in patients with psychosis.

Previous studies suggested that African American patients with psychotic disorders receive higher doses of antipsychotic medication than white patients, are more likely to receive depot antipsychotics, and are less likely to be prescribed second-generation antipsychotics. African-American men in particular may be most likely to receive excessive doses of antipsychotics and depot antipsychotics, although this is less clear. Few studies have examined how sex and ethnicity interactions affect treatment of psychotic disorders. In this study, we examined whether the interaction of sex and ethnicity predicted the use of depot antipsychotics and the dosing of antipsychotics in a sample of inpatients with psychotic disorders. The inpatient records of 167 patients with psychotic disorders were evaluated for type and dose of medication at discharge. African-American men received depot antipsychotic medication more frequently than African-American women and white patients. This difference persisted after controlling for sociodemographic and clinical variables. African-American men and women with psychotic mood disorders were also more likely to be discharged on high antipsychotic doses compared with white patients. There were no ethnic or sex differences in the dosing of antipsychotics for the treatment of schizophrenia spectrum disorders. There were also no ethnic or sex differences in the use of second-generation antipsychotics.

Ethnicity and first-rank symptoms in patients with psychosis.

Previous studies suggested that African-American patients with psychotic disorders present more commonly with first-rank symptoms. However, it was unclear whether these results reflected true differences among African- and Euro-Americans in symptom presentation or instead resulted from raters being more likely to assign first-rank symptoms to African-American patients. In this study, a total of 195 African- and Euro-American patients presenting for hospitalization with psychosis were evaluated using structured diagnostic and symptom rating instruments; this evaluation was audiotaped. The tapes were transcribed and all cues indicating the patient's ethnicity were edited from the transcript and from medical records. Two board-certified psychiatrists then evaluated the transcripts and medical records in order to make consensus expert diagnosis and rate first-rank symptoms. Ratings of first-rank symptoms in African- and Euro-American patients were compared between ethnicity-blinded expert consensus assessments and the unblinded structured interview. African-American men received higher first-rank symptom ratings than the remaining patient groups by both ethnicity-blinded expert consensus and unblinded structured interview. African-American men also had significantly more total psychotic symptoms than Euro-American men. However, the ethnically blinded expert consensus did not find an increased rate of schizophrenia in the African-American men. These findings indicate that psychotic symptom presentation should be evaluated in the context of other symptoms (e.g., affective symptoms) in diagnostic assessments in order to prevent misdiagnoses of schizophrenia.

Verbal memory in mania: effects of clinical state and task requirements.

OBJECTIVES: Manic patients exhibit impaired verbal learning and memory, particularly following longstanding illness. However, it is unclear whether recognition and recall performance are differentially influenced by a manic mood state. METHODS: To examine this issue, we administered the California Verbal Learning Test and symptom-rating scales to inpatients with pure or mixed mania, euthymic outpatients, and healthy comparison subjects. RESULTS: An overall performance difference was identified between groups. Manic and euthymic patients performed more poorly than healthy subjects on recall. However, manic patients performed more poorly than euthymic patients and healthy subjects on recognition. CONCLUSIONS: These results suggest that verbal retrieval deficits are stable vulnerability indicators in bipolar disorder, whereas verbal encoding deficits are manic episode indicators. The known subcortical dysfunction in this disorder may produce stable retrieval deficits while acute mood symptoms attenuate encoding during affective episodes only.

Ethnicity and diagnosis in patients with affective disorders.

BACKGROUND: Clinically, African American psychiatric patients are disproportionately diagnosed with schizophrenia compared with white patients. Why this occurs is unknown. Extending prior work, the authors hypothesized that first-rank symptoms distract clinicians so that they fail to identify affective disorders in African Americans. METHOD: 195 African American and white patients with at least 1 psychotic symptom (delusions, hallucinations, or prominent thought disorder) at admission were recruited from January 1, 1998, through May 31, 2001. Each patient received 3 independent DSM-IV diagnoses: a clinical diagnosis, a structured-interview diagnosis, and an expert-consensus diagnosis. The expert-consensus diagnoses were derived from the structured interviews, which were audiotaped and transcribed, and medical records. After reviewing edited transcripts and medical records from which ethnic cues had been eliminated, 2 psychiatrists assigned expert-consensus diagnoses and first-rank symptom ratings. For the 79 patients who received an expert-consensus diagnosis of an affective disorder, clinical variables, diagnoses, and first-rank symptoms were compared between African American (N = 39) and white (N = 40) patients. RESULTS: Seventy-nine (41%) of 195 patients were diagnosed with an affective disorder by expert consensus. African American men with an expert-consensus affective disorder were significantly (p <.03) more likely than other patients to be diagnosed with a schizophrenia spectrum disorder by clinical assessment and structured interview. Although first-rank symptoms were more commonly identified in African American men, this finding did not explain the difference in diagnoses. Post hoc analyses suggested that African American men diagnosed with a schizophrenia spectrum disorder were more likely than other patients to have been identified during structured interview as having psychotic symptoms in the absence of affective symptoms. CONCLUSION: The apparent misdiagnosis of schizophrenia in African-Americans with mood disorders cannot be ascribed to differences in first-rank symptoms. However, it may be due to a perception that psychotic symptoms are more chronic or persistent than affective symptoms in these patients.