Does Length of Relationship or Gender Predict Response to Behavioral Diabetes Intervention?

Purpose The purpose of the study was to determine, through secondary analysis, whether the length of a couple's relationship and the participants' gender are associated with glycemic response to a type 2 diabetes (T2D) behavioral couples-based intervention. Methods A randomized trial was conducted to test the impact of a couples-level, telephone-based behavioral intervention on hemoglobin A1C in patients with T2D. One hundred and four patients and partners participated in the couples intervention arm, and 94 individuals participated in the individual arm. A1C levels were measured at baseline and 1-year follow-up. Results Results of the regression analysis showed that for men with T2D (n = 35) in the couples intervention group, longer length of relationship was associated with lower A1C at 1-year follow-up, after controlling for baseline A1C, diabetes duration, and income. Length of relationship was not significantly related to follow-up glycemic measures for women or men with T2D in the individual intervention. Conclusions Study findings suggests that for men with T2D in a couples-based intervention, those in longer relationships may be more likely to benefit from the intervention. More research is needed to better understand factors that contribute to successful couples-based behavioral approaches to help adults with T2D improve their glycemic control.

Health and Psychosocial Outcomes of a Telephonic Couples Behavior Change Intervention in Patients With Poorly Controlled Type 2 Diabetes: A Randomized Clinical Trial.

OBJECTIVE: To compare glycemic control and secondary outcomes of a 4-month telephonic couples behavioral intervention to individual intervention, and to education, for adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: A randomized trial with the following three arms: couples calls (CC) (n = 104); individual calls (IC) (n = 94); and diabetes education (DE) (n = 82). All arms had self-management education (two calls). CC and IC had 10 additional behavior change calls. CC addressed collaboration and relationships/communication. Participants consisted of 280 couples, among whom one partner had type 2 diabetes and an A1C level ≥7.5%. Blinded assessments occurred at 4, 8, and 12 months. The primary outcome was change in A1C; and secondary outcomes were BMI, waist circumference, blood pressure, depressive symptoms, diabetes self-efficacy, and diabetes distress. RESULTS: Patients had a mean age of 56.8 years; 61.6% were male, and 30.4% were minorities. The baseline mean A1C level was 9.1%. Intention-to-treat analyses found significant A1C reductions for all (12 months: CC -0.47%, IC -0.52%, DE -0.57%), with no differences between arms. Preplanned within-arm analyses were stratified by baseline A1C tertiles: lowest tertile (7.5-8.2%), no change from baseline; middle tertile (8.3-9.2%), only CC led to significantly lower A1C level; and highest tertile (≥9.3%), significant improvement for all interventions. For BMI, CC showed significant improvement, and CC and DE led to decreased waist circumference. The IC group showed greater blood pressure improvement. Results for secondary psychosocial outcomes favored the CC group. CONCLUSIONS: In adults with poorly controlled type 2 diabetes, a collaborative couples intervention resulted in significant, lasting improvement in A1C levels, obesity measures, and some psychosocial outcomes. For those with exceedingly high A1C levels, education alone was beneficial, but additional intervention is needed to achieve glycemic targets.

Personal and relationship challenges of adults with type 1 diabetes: a qualitative focus group study.

OBJECTIVE: Little is known about the psychosocial challenges of adults living with type 1 diabetes or its impact on partner relationships. This qualitative study was undertaken to gain better understanding of these issues. RESEARCH DESIGN AND METHODS: Four focus groups were held, two with adult type 1 diabetic patients (n = 16) and two with partners (n = 14). Two broad questions were posed: "What are the emotional and interpersonal challenges you have experienced because you have (your partner has) type 1 diabetes?" and "How does the fact that you have (your partner has) type 1 diabetes affect your relationship with your partner, positively and/or negatively?" Sessions were recorded and transcribed, and analyzed by a team of four researchers, using constant comparative methods to identify core domains and concepts. RESULTS: Four main domains were identified: 1) impact of diabetes on the relationship, including level of partner involvement, emotional impact of diabetes on the relationship, and concerns about child-rearing; 2) understanding the impact of hypoglycemia; 3) stress of potential complications; and 4) benefits of technology. Themes suggest that, although partner involvement varies (very little to significant), there exists significant anxiety about hypoglycemia and future complications and sources of conflict that may increase relationship stress. Partner support is highly valued, and technology has a positive influence. CONCLUSIONS: Adults with type 1 diabetes face unique emotional and interpersonal challenges. Future research should focus on gaining a better understanding of how they cope and the effect of psychosocial stressors and coping on adherence, quality of life, and glycemic control.

Varenicline treatment of concurrent alcohol and nicotine dependence in schizophrenia: a randomized, placebo-controlled pilot trial.

Alcohol and nicotine dependence are common in schizophrenia. Varenicline is effective in smoking cessation and has also been shown to decrease alcohol consumption in smokers. The present pilot study assessed the safety and effectiveness of varenicline for treatment of concurrent nicotine and alcohol dependence in schizophrenia. Outpatients with schizophrenia or schizoaffective disorder and concurrent alcohol and nicotine dependence were enrolled in this 8-week, double-blind, randomized, placebo-controlled trial. Alcohol use and smoking were assessed using self-report (Timeline Follow-Back) and biological measures. Adverse events were recorded. Changes in the number of standard drinks per week and cigarettes per week were compared in the 2 groups. Because of safety concerns or loss to follow-up, of 55 patients enrolled, only 10 started study medication, 5 each on varenicline and placebo. Gastrointestinal adverse effects, such as severe abdominal pain, limited study completion to only 4 subjects. Number of standard alcoholic drinks consumed per week decreased by [mean (SD)] 16.6 (20.1) in the varenicline group and by 2.4 (27.4) in the placebo group. Mean (SD) number of cigarettes smoked per week decreased by 66 (65) in the varenicline group and by 47 (77) in the placebo group. Varenicline treatment of concurrent alcohol and nicotine dependence in schizophrenia may be problematic because of safety concerns limiting recruitment and poor tolerability (gastrointestinal adverse effects) limiting retention. There was no increased number of serious neuropsychiatric adverse events in the varenicline group. Based on this small sample, concurrent alcohol and nicotine dependence in schizophrenia may present special obstacles to successful treatment with varenicline.

Predictors of smoking severity in patients with schizophrenia and alcohol use disorders.

The goal of the present study was to identify predictors of smoking severity in patients with schizophrenia and co-occurring alcohol use disorders (AUD). Our hypothesis was that negative symptoms of schizophrenia, severity of depression, male gender, drinking severity, and recreational drug use were associated with increased smoking. Clinical data, including demographic variables, alcohol and substance use severity, psychiatric medications, severity of depression, positive and negative symptoms of schizophrenia were analyzed in a cohort of 90 patients with schizophrenia or schizoaffective disorder and AUD. Eighty-eight percent of participants were smokers, they smoked an average of 15 cigarettes/day. Zero-inflated negative binomial (ZINB) regression analyses demonstrated that alcohol use severity, gender, and severity of negative symptoms were not predictive of the number of cigarettes smoked. Smoking severity was positively related to Caucasian race, psychosis severity (Positive and Negative Syndrome Scale [PANSS] general score), and medications (conventional antipsychotics). Subjects who used recreational drugs smoked less. In summary, severe, treatment resistant schizophrenia, and conventional antipsychotic treatment is associated with heavy smoking in patients with schizophrenia and AUD regardless of gender or alcohol use.

Accuracy of self-reported medical problems in patients with alcohol dependence and co-occurring schizophrenia or schizoaffective disorder.

BACKGROUND: Schizophrenia and alcohol dependence (AD) are both major risk factors for a variety of medical problems, yet little is known about the medical status of patients in whom both conditions coexist. OBJECTIVE: The objectives of this study are to assess accuracy of self-reported medical problems and to compare the accuracy reports in patients with schizophrenia or schizoaffective disorder and co-occurring AD compared to patients with AD only and to controls. Our hypothesis was that medical problems are under-reported in patients with co-occurring disorders, possibly due to the combination of alcohol use and symptoms of schizophrenia. METHODS: Self-reported medical diagnoses were recorded and compared to medical records obtained from all area hospitals in 42 patients with schizophrenia and AD, 44 patients with schizoaffective disorder and AD, 41 patients with AD only, and 15 control subjects. Patients underwent medical history, physical examination, and review of medical records. RESULTS: Patients with schizophrenia or schizoaffective disorder and co-occurring AD underreported their medical problems significantly more than patients with AD only and controls. Accuracy of self report was significantly lower in patients with schizophrenia-spectrum disorders plus co-occurring alcohol dependence than in AD alone or in controls. The most commonly underreported diagnoses included coronary artery disease, chronic renal failure, seizure disorder, hyperlipidemia, asthma and hypertension. DISCUSSION: In order to detect potentially unreported medical conditions in patients with co-occurring schizophrenia/schizoaffective disorder and alcohol dependence, the use of targeted screening questionnaires is recommended in addition to physical examination and thorough review of medical records.

Patient and provider attitudes towards monitored naltrexone treatment of alcohol dependence in schizophrenia.

OBJECTIVE: To describe the attitudes of patients and their mental health providers regarding participation in a controlled trial of directly monitored naltrexone (NTX) treatment for alcohol dependence in schizophrenia. METHOD: Ninety participants with schizophrenia and their providers were asked to report opinions of treatment with oral NTX or placebo 3 times per week for 12 weeks, motivational counseling (MI), and voucher-based incentives (VBI) for attendance. RESULTS: Seventy-nine percent of participants "liked the study a lot," and 94% reported that it was helpful. Study components rated as helpful by participants were: VBI (95% of participants), meeting with staff 3 times per week (84%), reporting alcohol use (82%), MI (82%), reporting psychiatric symptoms (73%), breath alcohol testing (72%), and study medication (57%). Benefits reported by patients were: feeling better mentally (67%), drinking less (52%), feeling better physically (49%), and stopping drinking (27%). Seventy percent of providers reported that the study was helpful. Benefits noted by providers included: reduced drinking (33%), better treatment adherence (32%), stopping drinking (23%), and reduced psychiatric symptoms (22%). Patient/provider responses agreed on helpfulness with stopping or reducing drinking. CONCLUSIONS: Most participants with schizophrenia liked participating in a clinical trial of directly observed naltrexone treatment for alcohol dependence, and found incentives for attendance, frequent staff contact and monitoring of drinking, and motivational counseling to be the most helpful. Most participants reported improvement in mental health and reduced drinking. Mental health providers also reported that the study was helpful, but they did not describe the same degree of benefit as did patients.

Medical comorbidity in patients with schizophrenia and alcohol dependence.

BACKGROUND: Schizophrenia and alcohol dependence are major risk factors for a variety of medical problems, yet there has been little research on the medical status of patients in whom both conditions coexist. METHODS: We assessed the prevalence and severity of medical illness in 80 patients with schizophrenia or schizoaffective disorder and comorbid alcohol use disorders who entered a controlled trial of monitored naltrexone treatment, and analyzed the relationship between medical illness burden and demographic variables, alcohol and other substance use, and psychosis. Participants underwent physical examination, laboratory tests, medical record review and standardized assessments of medical illness burden, alcohol and other substance use, and psychosis. Nested block multiple regression analyses were used to assess the contribution to illness burden made by demographic variables, alcohol and substance use, and psychosis severity. RESULTS: 83% of participants had at least one chronic medical illness, hypertension being the most common (43%). Medical comorbidity in this cohort was more severe than for schizophrenia patients in the CATIE trial (Chwastiak, L., Rosenheck, R., McEvoy, J.P., Keefe, R.S., Swartz, M.S., Lieberman, J.A., 2006. Interrelationships of Psychiatric Symptom Severity, Medical Comorbidity, and Functioning in Schizophrenia. Psychiatr. Serv., 57(8), 1102-1109.); the prevalence of hypertension, chronic obstructive pulmonary disease, and coronary artery disease, was more than twice greater. Medical illness burden correlated with alcohol use severity, but appeared to be independent of other substance use or psychosis severity. CONCLUSIONS: Patients with co-occurring alcohol use disorder may have significantly more medical illness burden than patients with schizophrenia or schizoaffective disorder alone. Interventions to reduce alcohol use may be necessary to lessen medical morbidity.

Negative symptoms are associated with less alcohol use, craving, and "high" in alcohol dependent patients with schizophrenia.

BACKGROUND: Alcohol use disorders (AUDs) frequently co-occur with and exacerbate schizophrenia, yet the specific relationships between schizophrenia symptoms and alcohol use remain unclear. METHODS: PANSS scores were correlated with measures of alcohol and other substance use in patients with schizophrenia-spectrum disorders and AUDs entering a trial of monitored naltrexone treatment. Data were analyzed from the first 80 participants; 55% had schizophrenia and 45% had schizoaffective disorder. All had AUDs; 95% had alcohol dependence and 5% alcohol abuse; 34% also had cannabis abuse/dependence and 31% cocaine abuse/dependence. RESULTS: PANSS Negative scores were inversely correlated with Addiction Severity Index alcohol composite scores, alcohol craving, quality of alcohol "high" (euphoria), and with frequency of cannabis use. An exploratory analysis indicated that the negative symptoms that may most strongly correlate with less alcohol use, craving and/or euphoria were passive/apathetic social withdrawal, blunted affect, difficulty in abstract thinking, and stereotyped thinking. Higher PANSS Composite scores, indicating the predominance of positive over negative PANSS symptoms, correlated with more alcohol craving and cannabis use. Higher PANSS General scores were associated with more alcohol craving. CONCLUSIONS: These findings extend previous reports of the association of negative schizophrenia symptoms with less alcohol and substance use to patients with AUDs and indicate that this relationship also includes less alcohol craving and less alcohol euphoria. The findings may also provide some initial evidence that specific negative symptoms may be keys to these relationships.

Voucher-based incentives for naltrexone treatment attendance in schizophrenia and alcohol use disorders.

OBJECTIVE: This study assessed the feasibility of voucher-based incentives for attendance for directly observed naltrexone treatment in a controlled trial for alcohol use disorders in schizophrenia. METHODS: Cash-value voucher-based incentives were contingent on attendance at three research visits per week over 12 weeks for 61 participants. Vouchers increased in value based on consecutive attendance. Missed visits resulted in reduction of voucher value. RESULTS: Participants attended 82% of all research visits. Average value of vouchers earned was $330 (78% of the maximum possible). Psychotic symptom severity at baseline did not affect the utilization of vouchers, and 94% of participants perceived the incentive system as helpful. CONCLUSIONS: The incentive system was well accepted and used despite psychosis severity, and the attendance rate was high, although causality between incentives and attendance could not be examined. A voucher-based incentive system for attendance can be successfully applied in a clinical trial for alcohol dependence treatment in schizophrenia.

Monitored naltrexone without counseling for alcohol abuse/dependence in schizophrenia-spectrum disorders.

This clinical trial assessed the effects of monitored naltrexone treatment in 19 subjects with schizophrenia spectrum and alcohol use disorders in an eight-week prospective open pilot study. Naltrexone was directly administered to subjects in oral doses of 100 mg on Mondays and Wednesdays, and 150 mg on Fridays. Subjects received reimbursement for attending the three weekly study visits. Subjects continued to receive their usual psychiatric care with no added alcohol counseling provided. Alcohol use was assessed by self-report and biomarkers. Psychosis severity was measured by the Positive and Negative Syndrome Scale (PANSS). Subjects reported significant reductions in their number of drinks per week, drinks per drinking day, days of drinking to intoxication, and alcohol craving. Subjects also showed significant reductions in Addiction Severity Index (ASI) alcohol composite scores and in PANSS positive, negative and general psychopathology scores.

Adapting Motivational Interventions for Comorbid Schizophrenia and Alcohol Use Disorders.

The co-occurrence of schizophrenia and alcohol use disorders often leads to poor treatment retention and adherence. Both empirical research and statements of best practices suggest that interventions including motivational interviewing principles can enhance treatment engagement and improve outcomes. This article describes a set of exercises used within a motivational enhancement protocol for outpatients with schizophrenia-spectrum and alcohol use disorders. We describe how each exercise was tailored to the target population, and how it is designed to enhance motivation to change and treatment engagement. Examples from clinical transcripts are used to demonstrate how motivational interviewing is adapted to the cognitive, social, and environmental circumstances associated with schizophrenia.