Screening for Complicated Grief in a Military Mental Health Clinic.

INTRODUCTION: Bereavement is one of the most common and stressful life experiences one can endure. Typical grief reactions follow a course of recovery in which individuals come to terms with the loss and resume functioning within weeks to months. However, for some, grief remains indefinitely distressing. Complicated Grief (CG) refers to significant chronic impairment that stems from bereavement. Military service members experience myriad factors that likely increase their risk for developing CG. Such factors include unique bonds between service members, exposure to constant and extreme levels of stress, multiple losses, separation from family and loved ones, witnessing/learning about sudden violent and traumatic deaths, and handling human remains. The aim of this project was to explore the practicality and efficiency of screening for CG within a busy military mental health clinic, and also explore relationships between contextual variables related to a death that might be associated with screening positive for CG. MATERIALS AND METHODS: As part of a clinical needs assessment, patients from a single mental health clinic at Naval Medical Center San Diego completed a brief grief survey that asked if they experienced a death of a person close to them, collected metrics related to losses they have experienced and included validated screeners for CG (The Brief Grief Questionnaire [BGQ] and the Inventory for Complicated Grief [ICG]). No data concerning gender, age, marital status, socioeconomic status, diagnosis, or purpose of visit (i.e., initial or follow-up visit) were collected. Institutional review board approval was obtained. RESULTS: In our sample of service members presenting to an adult outpatient military mental health clinic, 43.5% reported having experienced a loss that still impacts them. Of that group, 61.7% screened positive on the BGQ, 59.2% screened positive on the ICG using a cutoff of 25, and 46.1% screened positive on the ICG using the cutoff of 30. These findings suggest that military service members seeking mental health treatment who endorsed experiencing a loss are at high risk for experiencing persisting, impairing grief. Additionally, patients who either lost a fellow service member and/or experienced loss while on deployment reported significantly higher scores on the BGQ or ICG than if they did not report those factors. Furthermore, correlations between total number of losses and ICG scores suggest that service members who experienced multiple losses may be more susceptible to CG symptoms. CONCLUSION: The findings from this preliminary investigation suggest that many service members receiving care in military mental health care are experiencing grief-related symptoms and distress, and a brief screen for grief can help capture many of those with grief related impairment. Research shows that CG needs to be directly targeted to treat its symptoms and associated impairment. We recommend that military mental health clinics consider adding some type of grief screener to their standard intake as well as making providers aware of the importance of monitoring potential grief reactions in their patients.

Adding antidepressants to antipsychotics for treatment of subsyndromal depressive symptoms in schizophrenia: Impact on positive and negative symptoms.

OBJECTIVES: It remains unclear how augmenting anti-psychotic medications with anti-depressants impacts primary positive and negative symptoms of schizophrenia. In this study, we used data collected from a randomized trial comparing citalopram to placebo for management of subsyndromal depression (SSD) in schizophrenia and schizoaffective disorder, to assess the effects of antidepressant augmentation on positive and negative symptoms. MATERIALS AND METHODS: Participants in this study conducted at the University of California, San Diego and the University of Cincinnati, were persons with schizophrenia or schizoaffective disorder aged 40 or older and who met study criteria for SSD. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current anti-psychotic medication. Analysis of covariance was used to compare changes in positive and negative syndrome scale (PANSS) scores between treatment groups. We also assessed mediating effects of improvement in depression and moderating effects of multiple factors on positive and negative symptoms. RESULTS: There was significant improvement in PANSS negative symptoms scores in the citalopram group, which was partially mediated by improvement in depressive symptoms. There was no effect on PANSS positive scores. CONCLUSIONS: In patients with schizophrenia/schizoaffective disorder, treating depressive symptoms with citalopram appears to carry the added benefit of improving negative symptoms.

Incarceration among adults who are in the public mental health system: rates, risk factors, and short-term outcomes.

OBJECTIVE: Incarceration of people with mental illness has become a major social, clinical, and economic concern, with an estimated 2.1 million incarcerations in 2007. Prior studies have primarily focused on mental illness rates among incarcerated persons. This study examined rates of and risk factors for incarceration and reincarceration, as well as short-term outcomes after incarceration, among patients in a large public mental health system. METHODS: The data set included 39,463 patient records combined with 4,544 matching incarceration records from the county jail system during fiscal year 2005-2006. Risk factors for incarceration and reincarceration were analyzed with logistic regression. Time after release from the index incarceration until receiving services was examined with survival analysis. RESULTS: During the year, 11.5% of patients (N=4,544) were incarcerated. Risk factors for incarceration included prior incarcerations; co-occurring substance-related diagnoses; homelessness; schizophrenia, bipolar, or other psychotic disorder diagnoses; male gender; no Medicaid insurance; and being African American. Patients older than 45, Medicaid beneficiaries, and those from Latino, Asian, and other non-Euro-American racial-ethnic groups were less likely to be incarcerated. Risk factors for reincarceration included co-occurring substance-related diagnoses; prior incarceration; diagnosed schizophrenia or bipolar disorder; homelessness; and incarceration for three or fewer days. Patients whose first service after release from incarceration was outpatient or case management were less likely to receive subsequent emergency services or to be reincarcerated within 90 days. CONCLUSIONS: Modifiable factors affecting incarceration risk include homelessness, substance abuse, lack of medical insurance, and timely receipt of outpatient or case management services after release from incarceration.

Do psychiatry residents identify as psychotherapists? A multisite survey.

BACKGROUND: Psychiatric training was once synonymous with learning psychotherapy, but current psychiatric trainees face many options for integrating psychopharmacology and psychotherapy into their future practices, including providing primarily medication-focused visits. We examined psychiatry residents' attitudes towards learning psychotherapy, practicing psychotherapy in the future, and overall identification as psychotherapists. METHODS: We surveyed residents from 15 US residency programs during 2006-2007. The survey included 36 Likert-scaled items inquiring about residents' attitudes towards their psychotherapy training and supervision, their level of psychotherapy competence, the role of psychotherapy in their psychiatric identity, and their future practice plans. Four items asked about personal psychotherapy experience. Here we describe findings related to attitudes concerning being a psychotherapist and future practice plans. RESULTS: Among 249 respondents, most (82%) viewed becoming a psychotherapist as integral to their psychiatric identity. Fifty-four percent planned to provide formal psychotherapy, whereas 62% anticipated psychopharmacology would be the foundation of treatment for most patients. Residents with personal psychotherapy experience and first-year postgraduate residents (PGY-1) were more likely to identify as psychotherapists, plan to pursue further psychotherapy training postresidency, and anticipate psychotherapy being central to their future practice. CONCLUSIONS: Despite concerns about the diminishing role of psychotherapy in the practice of psychiatry and in psychiatrists' professional identity, most psychiatric residents view psychotherapy as integral to their professional identities and future practice plans.

Augmentation with citalopram for suicidal ideation in middle-aged and older outpatients with schizophrenia and schizoaffective disorder who have subthreshold depressive symptoms: a randomized controlled trial.

OBJECTIVE: To examine the effects of citalopram augmentation of antipsychotics on suicidal ideation in middle-aged and older people with schizophrenia and subthreshold depressive symptoms. METHOD: In this placebo-controlled trial conducted from September 1, 2001, to August 31, 2007, 198 outpatients > or = 40 years old with DSM-IV-diagnosed schizophrenia or schizoaffective disorder and subthreshold depressive symptoms were randomly assigned to flexible-dose citalopram (n = 104) or placebo (n = 94) augmentation of their antipsychotic for 12 weeks. Depression was measured with the Hamilton Depression Rating Scale (HDRS) and Calgary Depression Rating Scale (CDRS). Primary suicidal ideation measures were the Clinical Global Impressions-Severity of Suicide scale (CGI-SS) and the InterSePT Scale for Suicidal Thinking (ISST); secondary outcomes were the Scale for Suicidal Ideation (SSI), Beck Hopelessness Scale (BHS), HDRS item 3, and CDRS item 8. RESULTS: Compared to placebo, at the final visit, citalopram was associated with lower BHS scores (4.21 vs 4.98; P < .05) and lower likelihood of having suicidal ideation on the ISST (17.7% vs 38.7%; P < .005) and HDRS item 3 (14.4% vs 22.6%; P < .05). Among the 114 participants with no baseline suicidal ideation, there were no significant differences between citalopram and placebo regarding "emergent" ideation on either primary outcome. Among the 55 participants with baseline suicidal ideation, fewer treated with citalopram had endpoint ideation on the ISST (28.6% vs 66.7%; P < .05). Significantly more depression responders than nonresponders went from having baseline suicidal ideation to no suicidal ideation on both the ISST (75.0% vs 31.4%; P < .05) and CGI-SS (84.6% vs 31.3%; P < .05). CONCLUSIONS: Treatment-emergent suicidal ideation was no more common with citalopram than placebo. In participants with baseline suicidal ideation, citalopram reduced suicidal ideation, especially in those whose depressive symptoms responded to treatment.

Association of posttraumatic stress disorder with increased prevalence of metabolic syndrome.

OBJECTIVE: Few studies have compared prevalence rates of metabolic abnormalities in antipsychotic-treated patients with different psychiatric disorders, including posttraumatic stress disorder (PTSD). In this study, we examined components of metabolic syndrome among middle-aged and older patients with psychiatric disorders. METHOD: In the study, 203 outpatients older than 40 years and with psychotic symptoms that needed antipsychotic treatment were enrolled. Among them, 65 had a diagnosis of schizophrenia, 56 had dementia, 49 had mood disorder, and 33 had PTSD. Clinical evaluations included medical history, use of psychotropic and other medications, adverse effects, physical examination, and clinical laboratory tests for metabolic profiles. RESULTS: Overall, the prevalence rates of metabolic syndrome were 72% in patients with PTSD, 60% in those with schizophrenia, 58% in those with mood disorder, and 56% in those with dementia. There were significant differences in body mass index, diastolic blood pressure, waist circumference, and high-density lipoprotein cholesterol among the 4 diagnostic groups. Posttraumatic stress disorder, schizophrenia, and mood disorder groups had significantly higher body mass indexes compared with the dementia group. The PTSD group also had significantly higher diastolic blood pressure compared with the dementia and mood disorder groups. CONCLUSIONS: Posttraumatic stress disorder may be associated with worsened metabolic profile. The overall frequency of metabolic syndrome and its components in patients with PTSD taking antipsychotics seemed to be at least equivalent, if not slightly worse, compared with that in patients with schizophrenia, dementia, or a mood disorder.

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review.

OBJECTIVE: Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos. METHODS: MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence. RESULTS: In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy. CONCLUSIONS: Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency.

OBJECTIVES: The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications. METHODS: Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status. RESULTS: Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients. CONCLUSIONS: Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.