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PubMed2003

Examination of treatment pattern differences by race.

Examine differences in treatment patterns among Blacks and non-Blacks in the U.S. Schizophrenia Care and Assessment Program. Baseline data from medical record abstraction, participant self-report and clinical assessment used to examine differences by race (race-gender pairings) (n = 2,239). Descriptive and multivariate (logistic) analysis employed. More Blacks were diagnosed with paranoid subtype. Blacks exhibited a more negative PANSS composite score, lower quality of life scores, and higher AIMS scores than non-Blacks. There was no statistically significant difference in the number of outpatient visits or inpatient admissions between Blacks and non-Blacks. Blacks had lower medication adherence and received less second-generation agents and more antiparkinson/anticholinergic agents. Proportion of Black males receiving depot was greater than other race-gender pairings. Regression results indicate Blacks more likely to be prescribed only first-generations after controlling for depot (OR = 1.64; CI = 1.27-2.12; p = 0.0002). Schizophrenia is, on average, accompanied by different diagnoses and symptoms in Blacks. Symptom profiles indicate that second-generation antipsychotics may be underprescribed to Black patients.

Black or African American↗

PubMed2002

Psychosocial factors in peptic ulcer and inflammatory bowel disease.

Over the past decade, while gastroenterologists' interest in mind-body interactions in organic disorders dwindled, stronger evidence has linked psychosocial factors with the incidence and recurrence of peptic ulcer and with the course of inflammatory bowel disease. Psychological-behavioral approaches to treatment continue to be disappointing. Psychosocial factors may affect ulcer by increasing duodenal acid load, altering local circulation or motility, intensifying Helicobacter pylori infection, stimulating corticosteroid secretion, and affecting health risk behaviors; possible mechanisms for inflammatory bowel disease include immune deregulation, gut permeability changes, and poor medication adherence. Both belong to the growing category of diseases thought to have an infectious component: for peptic ulcer the bacterium Helicobacter pylori, for inflammatory bowel disease an exaggerated immune response to gut bacteria. Peptic ulcer and inflammatory bowel disease, which present unique interactions among psychological, immunologic, endocrine, infectious, and behavioral factors, are splendid paradigms of the biopsychosocial model.

Helicobacter Infections↗

PubMed2003

Subjective well-being and initial dysphoric reaction under antipsychotic drugs - concepts, measurement and clinical relevance.

Since the introduction of neuroleptics in 1952, many studies have examined objective aspects of efficacy and tolerability. Despite the fact that neuroleptic treatment should also improve the patient's subjective experiences, this outcome criterion has been neglected in the past. This is unfortunate, as subjective well-being with treatment appears to be strongly related to patients' readiness to take their medication. The few existing studies differ in methodology and are difficult to compare due to a number of weaknesses, including varying underlying concepts, used assessment scales, or small sample sizes. Negative subjective well-being may manifest itself throughout the entire neuroleptic treatment, even as early as in the first 48 hours after neuroleptic treatment starts (initial dysphoric reaction, IDR). The aetiology of reduced subjective well-being or IDR is not fully explained; neuroleptic side effects, especially affective, cognitive and motor adverse events, differential effects of varying psychopathology or biopsychosocial are factors in discussion. The clinical impression is characterised by symptoms as dysphoria/anhedonia, reduced vitality, and emotional indifference, which could have a negative impact on relevant clinical factors such as response or medication adherence, and therefore on outcome. With regard to pharmacological treatment, evidence suggests that atypical antipsychotics induce less negative subjective effects than conventional neuroleptics, and that various new-generation antipsychotics could be evaluated differently by patients. This article reviews existing literature in order to approach relevant questions for pharmacotherapy.

Antipsychotic Agents↗

PubMed2002

Prevalence and correlates of household exposures to tobacco smoke and pets in children with asthma.

OBJECTIVES: To examine the prevalence rates of household smoking and ownership of a furred or feathered pet, the intercorrelation of these home environment measures, and their association with sociodemographic, family, and child asthma variables. STUDY DESIGN: Children with asthma (n = 152, aged 7-18 years) with asthma and their primary parent were evaluated through the use of reliable and valid questionnaires focusing on exposure to household smoke and furred or feathered pets as well as sociodemographic, family, and asthma variables. RESULTS: Prevalence of household smoking and pet ownership were high and comparable to normal levels in the US population. Smoking and pet ownership were not correlated with each other or with asthma medication adherence. Sociodemographic, family, and asthma variables showed distinct patterns of correlation with smoking and pet status. Household smoking was associated with poorer family resources and greater stress; pet ownership was associated with greater resources. CONCLUSIONS: Smoke exposure and pet ownership are not related to one another in children with asthma and will require independent counseling strategies because they relate in different and opposite ways to socioeconomic status.

Adolescent↗

PubMed2006

Behavioral therapy to augment oral naltrexone for opioid dependence: a ceiling on effectiveness?

The effectiveness of antagonist maintenance with oral naltrexone for opioid dependence has been limited by high dropout rates. Behavioral Naltrexone Therapy (BNT) was developed to improve retention on oral naltrexone by integrating voucher incentives, Motivational and Cognitive Behavioral therapies, and a significant other for monitoring medication adherence. In a 6-month, randomized, controlled trial in heroin dependent patients, BNT (N = 36) improved retention in treatment compared to a standard treatment control (Compliance Enhancement (CE); N = 33) (log rank = 4.28; p = .04). Most patients retained beyond 3 months achieved abstinence from opioids, but retention at 6 months was only 22% on BNT and 9% on CE. A systematic review of related controlled trials revealed similar effect sizes in the small to medium range, and substantial dropout. There may be a limit on the extent to which behavioral therapy can overcome poor adherence to oral naltrexone. Future research should consider combinations of behavioral methods with new long-acting injectable or implantable naltrexone formulations.

Behavior Therapy↗

PubMed2003

Assessing patients' perception of self-care agency in psychiatric care.

Self-care agency is necessary for psychiatric patients to maintain a level of health that will enable them to have a satisfying personal life as well as to participate in their communities. This article discusses some theoretical and operational dimensions of self-care agency in patients treated for psychiatric illness, with an emphasis on self-care agency in mood disorder. Tools for measuring self-care agency based on Orem's power components are available, but tools specific to psychiatric patients' strengths and deficits, such as in the area of medication adherence and symptom management, need to be developed.

Activities of Daily Living↗

PubMed2006

Perceived involvement in condition management among inner-city youth with asthma and their primary caregivers.

This study examined patterns of agreement versus disagreement in family perceptions of caregiver and youth involvement in asthma management tasks and associations of these patterns with youth asthma outcomes. Fifty-six caregiver-child dyads completed questionnaires of family involvement in asthma management and asthma health outcomes (i.e., symptom days, health care utilization, and medication adherence). Discrepancies were documented for perceptions of both caregiver and youth involvement. Caregiver overestimation of youth involvement in asthma management was associated with greater asthma severity and more asthma symptoms. Discrepancies in family perceptions of involvement pose salient challenges for effective clinical management and require clinical attention.

Adolescent↗

PubMed2001

Longitudinal predictors of depressive symptoms among low income injection drug users.

Effects of changes in physical health status and drug use, and prior social support on depressive symptoms were assessed in low income injection drug users. Data are from participants (n = 503) enrolled at baseline (1994-1995) who remained at one-year follow-up (79%), of whom 37% were HIV-positive and 36% female. Physical health was measured by HIV symptoms, AIDS, CD4 count and functional limitation (IADLs). One-third scored high on depressive symptoms (CES-D > or = 16) at one-year follow-up, representing no statistically significant change from baseline (38%). In multiple logistic regression, after controlling for baseline depression scores (OR = 6.11, p < 0.001) and drug use (OR = 1.20, p = 0.192), baseline functional limitation (OR = 3.28, p < 0.001) and declining functioning (OR = 3.60, p < 0.001) were positively, and quitting drug use was negatively, associated with depressive symptoms at follow-up. Low social support at baseline (OR = 0.58, p < 0.10) was marginally predictive of depressive symptoms. Depressive symptoms did not differ by gender. For HIV-positive respondents, functional limitation was predictive of depressive symptoms, but HIV illness and drug use were not. Facilitating drug treatment and preventive medical care may aid in reducing depression in this population. For HIV-positive drug users, drug treatment prior to AIDS may help reduce depressive symptoms, with potential implications for HIV service utilization and medical adherence.

Adult↗

PubMed2002

Women with HIV infection: a model of university-based care, training and research.

The growth of human immunodeficiency virus type-1 (HIV) infection among women in the USA has been coincident with an international momentum to better address the specific health care needs of women. This paper provides an overview of a demonstration model for comprehensive HIV care of adolescent and adult women in an academic setting. The paper contains a descriptive summary of a university-based demonstration model of comprehensive care for women with HIV infection. During 1997-1998, there were 279 urban and rural Midwest adolescent and adult women with HIV infection in care at this model programme. Medical care encompassed subspecialty HIV care, obstetrical and gynaecological care, primary care of non-HIV comorbidities, mental health assessments and family planning in a safe, university-based environment. For 279 women during the two-year period, health services included the detection and treatment of sexually transmitted diseases (56%) and cervical dysplasia (35%), perinatal care (12%) and screening and referral for substance abuse treatment (30%). There was no mother-to-child HIV transmission among 33 pregnant women enrolled in the Center prior to delivery, and transmission by three of nine women enrolled after delivery. Only 167 (60%) women were compliant with biannual medical visits during 1997-1998. Integral to the health services delivery was the provision of ancillary support services intended to enhance optimal medical care for this cohort of women. This university-based model of care also incorporated HIV provider training and formative HIV research. Structured medical and public health experiential learning opportunities occurred for medical and social work students, medicine residents, infectious diseases fellows, nurses and other professional health care workers. Clinical investigations of adolescent and adult women have complemented care and training, with funded research in HIV medication adherence and health services research. In follow-up, 71% of these women remained active in care in 1999. Retention of vulnerable populations in care may be a big challenge over the next decade, despite the availability of potent antiretroviral therapies.

Adolescent↗

PubMed2004

Collaborative management of HIV infection in the community: an effort to improve the quality of HIV care.

Our hospital led a multidisciplinary community team to improve the quality of care delivered to HIV-infected clients utilizing a disease management approach in a US metropolitan community of 150,000 people. Community needs assessment and client and community surveys were used to define the problems. Patient care flowcharting and the creation of an electronic patient database facilitated patient tracking across the entire community. Clinical guidelines and a consultation and referral immunology clinic standardized care practices. Measurable improvements in the quality of care were noted in multiple areas. Flowchart completion rates rose from 44% to 100%; medication adherence assessment rose from 82% to 100%; immunization rates rose from a mean of 72% to a mean of 87%; PPD screening rose from a low of 35% to a high of 87%; perinatal transmission rates fell from 31% to 4%; and Emergency Department utilization decreased. Two essential components of the effort were the establishment of a full-time leadership position in the form of a clinical nurse practitioner and the creation of an electronic database with flowcharting to standardize the measurement, delivery and tracking of care. The programme has become an example of successful disease management through hospital-community collaboration.

Adult↗

PubMed2002

Psychiatric complications in human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection is associated with psychiatric complications, including cognitive impairment, affective disorders, and psychosis. These psychiatric complications impair quality of life, affect disease prognosis, and impede treatment by compromising medication adherence. They also increase the likelihood of HIV transmission, either directly or via their high prevalence rate among drug abusers. In this article, the authors provide a brief overview of the most common psychiatric complications associated with HIV infection and discuss the role of dopamine as a link between psychiatric manifestations and the progression of immunodeficiency infection.

AIDS Dementia Complex↗

PubMed2001

Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study.

The feasibility of providing postexposure prophylaxis (PEP) after sexual or injection drug use exposures to human immunodeficiency virus (HIV) was evaluated. PEP was provided within 72 h to individuals with exposures from partners known to have or to be at risk for HIV infection. PEP consisted of 4 weeks of antiretroviral medications and individually tailored risk-reduction and medication-adherence counseling. Among 401 participants seeking PEP, sexual exposures were most common (94%; n=375). Among sexual exposures, receptive (40%) and insertive (27%) anal intercourse were the most common sexual acts. The median time from exposure to treatment was 33 h. Ninety-seven percent of participants were treated exclusively with dual reverse-transcriptase inhibitors, and 78% completed the 4-week treatment. Six months after the exposure, no participant developed HIV antibodies, although a second PEP course for a subsequent exposure was provided to 12%. PEP, after nonoccupational HIV exposure, is feasible for persons at risk for HIV infection.

Adolescent↗

PubMed2002

Addition of cyclophosphamide to antiretroviral therapy does not diminish the cellular reservoir in HIV-infected persons.

The chronically HIV-infected cellular reservoir in lymphoid tissue (LT) represents a formidable obstacle to the long-term success of antiretroviral therapy. Cytoreductive chemotherapy with cyclophosphamide (CTX) reduces cells in LT, and we hypothesized that coadministration of antiretroviral therapy with CTX may diminish the cellular reservoir over time. Ten antiretroviral treatment-naive subjects were recruited, and they received stavudine, lamivudine and nelfinavir (antiretroviral therapy, ART) until 2 consecutive plasma HIV RNA levels measured < 50 copies/ml (step 1). Five subjects then received ART alone, whereas five subjects received ART plus three escalating doses of CTX (step 2). Viral DNA was measured in LT obtained by excisional lymph node biopsy and peripheral blood mononuclear cells (PBMCs), using quantitative polymerase chain reaction at three time points in both groups (before steps 1 and 2, and after CTX). Viral DNA declined in both groups after the initiation of ART alone in step 1. During step 2 both groups experienced a modest decline compared with step 1. However, no significant differences were observed in viral DNA in LT or PBMCs between the ART alone and the ART plus CTX groups. Suppression of plasma HIV RNA levels < 50 copies/ml was not maintained in the ART plus CTX group, perhaps because of inadequate medication adherence. The group receiving ART plus CTX had lower CD4(+) lymphocyte counts and absolute total lymphocytes compared with the ART alone group. We conclude that the addition of CTX to ART did not diminish the cellular reservoir in HIV-infected persons.

Adolescent↗

PubMed2001

The psychosocial issues of children with perinatally acquired HIV disease becoming adolescents: a growing challenge for providers.

Today, providers caring for children who have perinatally acquired HIV disease treat them differently than they did less than a decade ago. As our knowledge of HIV and its treatment have grown, so have we and so have our children. We are seeing the first wave of adolescents with perinatally acquired HIV disease. This increased longevity has given new meaning to past challenges such as treatment regimens, medication adherence, disclosure, and permanency planning previously faced by providers, children, and their families. New challenges, such as adolescent treatment decisions, relationships, intimacy, college, and careers have been added to the list. As a prediatric nurse practitioner having "grown up" with perinatally acquired HIV disease in the last decade, I reflect on past challenges and offer a perspective on those that lie ahead. A multidisciplinary, family-centered support group intervention that was developed at our AIDS Center Program to assist families, older children, adolescents, and providers in facing these challenges is described.

Adaptation, Psychological↗

PubMed2005

Evaluation of an antiretroviral medication attitude scale and relationships between medication attitudes and medication nonadherence.

The objectives of this study were to refine a scale designed to assess attitudes toward antiretroviral medication, to examine variation in medication attitudes across clinical and demographic characteristics, and to assess relationships between medication attitudes and medication nonadherence. A cross-sectional design was used to survey individuals at least 18 years of age, currently on antiretroviral therapy, and served by a regional HIV/AIDS center. The survey was administered by pharmacy students using convenience sampling between February 2002 and August 2002. Nonadherence was measured using a nine-item scale with a higher score indicative of higher nonadherence. An antiretroviral medication attitude scale was developed based on revision of a zidovudine attitude inventory. The sample of 99 patients was predominantly male (79.8%), had an annual income of less than $10,000 (74%), and was comprised of 50% whites and 40.8% blacks. Participants were between 18 and 70 years old. Item reduction using item-total correlations and factor analytic techniques resulted in a 15-item medication attitude scale with good internal consistency (Cronbach alpha coefficient = 0.84). A multiple regression model showed a significant negative relationship between attitude toward medication and medication nonadherence after controlling for covariates including age, education, gender, ethnicity, work status, social support, CD4 cell count and number of antiretroviral medications, suggesting that more positive the attitude toward medication, lower the medication nonadherence. Findings underscore the importance of attitude toward medication as a modifiable factor that can be targeted to improve medication adherence.

Adolescent↗

PubMed2005

Assessing self-management information needs of persons living with HIV/AIDS.

In order to maximize their health status, persons living with HIV/AIDS must use a variety of self-management strategies. They learn these strategies from many sources often based on a specific need or problem. Information needs can be addressed during health care appointments but time is often limited and spent on more acute issues such as symptom control or medication adherence. In order to assess information needs, a 76-item HIV+ Information for Self-Care Quiz was developed and piloted with two samples. Both samples (n = 50, 43) were predominantly people of color and male with a mean age of either 44 or 56 years, respectively. This paper describes the phases of development and offers suggestions for its use in clinical settings, research, and provider education. By using this quiz to determine preexisting knowledge level, interactions with the health care provider can be more focused to address knowledge gaps and less time could be spent teaching information that the client already knows.

HIV Infections↗

PubMed2005

A brief mental health and substance abuse screener for persons with HIV.

Mental illness and substance abuse are common among HIV-infected individuals and are associated with negative outcomes, including poor medication adherence. Therefore, quick and effective methods for detecting these co-occurring disorders are necessary for health care practitioners. This article reports on the creation and preliminary testing of a brief screening tool, the Substance Abuse and Mental Illness Symptoms Screener (SAMISS). The 13-item screener was developed primarily from existing scales and administered to HIV-infected individuals receiving care at infectious diseases clinics in the Southeast. To assess the validity of the SAMISS, a subset of those who screened positive for both mental illness symptoms and substance use problems (n = 207) were administered the Structured Clinical Interview for DSMIV Disorders (SCID). The positive predictive value of the screener in comparison to the SCID was 98.6% for mental disorders and 98.6% for substance use disorders. The agreement between specific screener symptoms and their corresponding SCID diagnoses was relatively high for alcohol dependence (kappa = 0.50, p < 0.001), drug dependence (kappa = 0.30, p < 0.001), and drug abuse (kappa = 0.42, p <0.001). The finding that the screener is highly predictive of having a general mental disorder and substance use disorder among those screening positive for mental illness symptoms and substance use problems, as well as its brevity and ease of administration, make it a useful tool to detect symptoms of co-occurring disorders so that patients can be referred to mental health and substance abuse specialists. The screener is not a diagnostic instrument and has limited value in predicting specific psychiatric diagnoses.

Adult↗

PubMed2001

Evaluation of studies investigating the effectiveness of pharmacists' clinical services.

A quantitative evaluation of randomized trials of counseling, education, and other clinical services provided by pharmacists was performed. Data sources were MEDLINE and the bibliographies of published articles. Pharmacists' services were categorized as counseling of patients, counseling of physicians, counseling of both patients and physicians, and patient care. The outcomes extracted were measures of patient behavior, disease, symptoms, and patient knowledge. Thirty-two trials met the inclusion criteria. The pharmacists were specified as clinical pharmacists in 24 trials and as community pharmacists in 2. In six unblinded trials of patient counseling, the outcomes favored the counseled patients over control patients in every trial, and the effects were statistically significant in five trials (the outcome was medication adherence in these five trials). In seven trials of counseling of both patients and their physicians, patient outcomes were significantly better in the intervention group in six trials, four of which were single blind. Two trials in which patients were randomized to either physician counseling or control groups yielded inconsistent results. In one trial in which physicians were randomized to receive counseling from pharmacists, the proportion of prescriptions meeting guidelines was higher in the counseling group than in the control group. Four trials of patient care by pharmacists were inconclusive. These trials demonstrated that counseling of patients and their physicians by pharmacists can improve patient outcomes. The evidence that counseling of patients alone improved patient outcomes was good, though weaker because of suboptimal trial design.

Data Collection↗