A phenomenological inquiry into the costs and consequences of insomnia for veterans with serious mental illness.

Many individuals with serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments) have insomnia symptoms. Insomnia is a common reason for mental health referrals in the Veterans Health Administration. The primary aim of this study was to explore the costs (what participants lose or what trade-offs they make due to insomnia) and consequences (how insomnia impacts functioning) of insomnia for veterans with serious mental illness. Semi-structured interviews of 20 veterans with insomnia and serious mental illness were collected as data using an inductive phenomenological approach. Two main themes were identified: Sleep Affects Mental Health and Functioning; and Compromising to Cope. Results illuminate pathways by which sleep effort destabilizes functional recovery, and illustrate how sleep has multiplicative positive impacts on functioning and mood. Researchers and clinicians alike must explore supporting people with serious mental illness in replacing sleep effort with the recovery of meaningful identity-driven, values-based experiences formerly conceded due to serious mental illness, insomnia or both.

How do US military veterans with serious mental illness manage insomnia? A phenomenological analysis.

Insomnia is a prevalent experience for individuals with serious mental illness, and is one of the most common reasons for mental health referrals in the Veterans Health Administration. Insomnia also critically impacts psychiatric, cognitive and somatic outcomes. However, there is limited information about how people with serious mental illness (i.e. schizophrenia spectrum, bipolar, or major depressive disorders, with serious functional impairments) understand and respond to problems with their own sleep. Bringing this information to light will yield novel methods of research and treatment. The purpose of this study was to examine reactions to insomnia among veterans with serious mental illness and insomnia. An inductive phenomenological approach was used to collect data from 20 veterans with serious mental illness and insomnia using semi-structured interviews. Six themes were identified: Becoming Aware that Insomnia is a Problem; Response to and Dissatisfaction with Medications; Strategies to Get Better Sleep: Contrary to Usual Guidelines; Personal Responsibility for Getting Sleep; Resigned and Giving Up; and Acceptance and Persistence. These results provide insight into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold-standard treatments for chronic insomnia. Clinical implications and recommendations for improving treatment efficacy are discussed.

Frontal alpha asymmetry in schizotypy: electrophysiological evidence for motivational dysfunction.

Introduction: Schizotypy is defined as personality traits reflecting an underlying risk for schizophrenia-spectrum disorders. As yet, there is a dearth of suitable objective markers for measuring schizotypy. Frontal alpha asymmetry, characterised by reduced left versus right frontal region activity, reflects trait-like diminished approach-related systems and has been found in schizophrenia. Methods: The present study used electroencephalography (EEG) recorded on a consumer-grade mobile headset to examine asymmetric resting-state frontal alpha, beta, and gamma power within the multidimensional schizotypy (e.g. positive, negative, disorganised) during a three-minute "eyes closed" resting period in college undergraduates (n=49). Results: Findings suggest that schizotypy was exclusively related to reduced left versus right-lateralised power in the alpha frequency (8.1-12.9 Hz., R2= .16). Follow-up analysis suggested that positive schizotypy was uniquely associated with increased right alpha activity, indicating increased withdrawal motivation. Conclusions: Frontal asymmetry is a possible ecologically valid objective marker for schizotypy that may be detectable using easily accessible, consumer-grade technology.

A phenomenological inquiry into the experience of sleep: Perspectives of US military veterans with insomnia and serious mental illness.

The majority of people with serious mental illness experience insomnia, and insomnia is one of the most frequent reasons for mental health referrals in the Veterans Health Administration. Insomnia also represents a critical obstacle to mental health recovery. Little is known about how military veterans with mental health problems conceptualize their sleep and sleep problems; such information may uncover new avenues for research and treatment. Therefore, the purpose of this study was to explore how veterans with serious mental illness and insomnia experience and understand their sleep, towards the aim of identifying these new avenues. Participants included 20 veterans with insomnia and serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments). Data were collected via an inductive phenomenological approach using semi-structured interviews. We identified five themes: Sleep to Recharge; Sleep as a Fight; Sleep as Safety or Escape; Sleep as Dangerous; and Military Influence. Participants' relationship with sleep was complex; many associated it with intrusive and troubling hallucinations, paranoia and military experiences, yet at the same time desired sleep for its potential to liberate them from distress. Military mindsets both helped and hindered sleep. These results extend existing models of insomnia development and maintenance, and illuminate phenomena previously unidentified in this underserved veteran population. Clinical and theoretical implications are discussed, as well as new research directions for enhancing therapeutic efficacy.

Psychiatric Risk Assessment from the Clinician's Perspective: Lessons for the Future.

Accurate prediction of risk-states in Serious Mental Illnesses (SMIs) is critical for reducing their massive societal burden. Risk-state assessments are notably inaccurate. Recent innovations, including widely available and inexpensive mobile technologies for ambulatory "biobehavioral" data, can reshape risk assessment. To help understand and accelerate clinician involvement, we surveyed 90 multi-disciplinary clinicians serving SMI populations in various settings to evaluate how risk assessment is conducted and can improve. Clinicians reported considerable variability in conducting risk assessment, and few clinicians explicated their procedures beyond tying it to broader mental status examinations or interviews. Very few clinicians endorsed using currently-available standardized risk measures, and most reported low confidence in their utility. Clinicians also reported spending approximately half the time conducting individual risk assessments than optimally needed. When asked about improvement, virtually no clinicians acknowledged biobehavioral, objective technologies, or ambulatory recording. Overall, clinicians seemed unaware of meaningful ways to improve risk assessment.

Sharing positive events: Ecological momentary assessment of emotion regulation via social capitalization in schizotypy.

Emotional deficits are prominent in schizophrenia-spectrum psychopathology and linked with poorer outcomes. Schizotypy, an underlying personality organization that putatively confers vulnerability to developing schizophrenia, has been associated with increased negative affect, decreased positive affect, and some difficulty with emotion regulation. This study explored the role of social capitalization, the upregulation of positive emotion when positive life events are shared with others, in schizotypy. Social capitalization is relevant for schizotypy given its association with social functioning and social motivation abnormalities. Using mobile assessment methods, a sample of college students (N=73) completed daily surveys via a mobile application two times per day for seven days and made daily ratings of mood and answered questions regarding any capitalization attempt for a positive event. Results indicated that higher schizotypy and not sharing an event were independently associated with lower happiness and increased sadness and anxiety. When an event was shared, lower schizotypy and supportive/enthusiastic response perception were independently associated with increased happiness. No significant interactions were observed between schizotypy and social capitalization variables. Future research would benefit from exploring the role that other common schizotypy concomitants, e.g., social anxiety or social disconnection, play in social capitalization and the extent this is helped or hindered via mass personal technological mediums.

Digital phenotyping of negative symptoms: the relationship to clinician ratings.

Negative symptoms are a critical, but poorly understood, aspect of schizophrenia. Measurement of negative symptoms primarily relies on clinician ratings, an endeavor with established reliability and validity. There have been increasing attempts to digitally phenotype negative symptoms using objective biobehavioral technologies, eg, using computerized analysis of vocal, speech, facial, hand and other behaviors. Surprisingly, biobehavioral technologies and clinician ratings are only modestly inter-related, and findings from individual studies often do not replicate or are counterintuitive. In this article, we document and evaluate this lack of convergence in 4 case studies, in an archival dataset of 877 audio/video samples, and in the extant literature. We then explain this divergence in terms of "resolution"-a critical psychometric property in biomedical, engineering, and computational sciences defined as precision in distinguishing various aspects of a signal. We demonstrate how convergence between clinical ratings and biobehavioral data can be achieved by scaling data across various resolutions. Clinical ratings reflect an indispensable tool that integrates considerable information into actionable, yet "low resolution" ordinal ratings. This allows viewing of the "forest" of negative symptoms. Unfortunately, their resolution cannot be scaled or decomposed with sufficient precision to isolate the time, setting, and nature of negative symptoms for many purposes (ie, to see the "trees"). Biobehavioral measures afford precision for understanding when, where, and why negative symptoms emerge, though much work is needed to validate them. Digital phenotyping of negative symptoms can provide unprecedented opportunities for tracking, understanding, and treating them, but requires consideration of resolution.

Predicting self-injurious thoughts in daily life using ambulatory assessment of state cognition.

Self-injurious thoughts (SITs) fluctuate considerably from moment to moment. As such, "static" and temporally stable predictors (e.g., demographic variables, prior history) are suboptimal in predicting imminent SITs. This concern is particularly true for "online" cognitive abilities, which are important for understanding SITs, but are typically measured using tests selected for temporal stability. Advances in ambulatory assessments (i.e., real-time assessment in a naturalistic environment) allow for measuring cognition with improved temporal resolution. The present study measured relationships between "state" cognitive performance, measured using an ambulatory-based Trail Making Test, and SITs. Self-reported state hope and social connectedness was also measured. Data were collected using a specially designed mobile application (administered 4x/week up to 28 days) in substance use inpatients (N = 99). Consistent with prior literature, state hope and social connectedness was significantly associated with state SITs. Importantly, poorer state cognitive performance also significantly predicted state SITs, independent of hallmark static and state self-report risk variables. These findings highlight the potential importance of "online" cognition to predict SITs. Ambulatory recording reflects an efficient, sensitive, and ecological valid methodology for evaluating subjective and objectives predictors of imminent SITs.

Validating Biobehavioral Technologies for Use in Clinical Psychiatry.

The last decade has witnessed the development of sophisticated biobehavioral and genetic, ambulatory, and other measures that promise unprecedented insight into psychiatric disorders. As yet, clinical sciences have struggled with implementing these objective measures and they have yet to move beyond "proof of concept." In part, this struggle reflects a traditional, and conceptually flawed, application of traditional psychometrics (i.e., reliability and validity) for evaluating them. This paper focuses on "resolution," concerning the degree to which changes in a signal can be detected and quantified, which is central to measurement evaluation in informatics, engineering, computational and biomedical sciences. We define and discuss resolution in terms of traditional reliability and validity evaluation for psychiatric measures, then highlight its importance in a study using acoustic features to predict self-injurious thoughts/behaviors (SITB). This study involved tracking natural language and self-reported symptoms in 124 psychiatric patients: (a) over 5-14 recording sessions, collected using a smart phone application, and (b) during a clinical interview. Importantly, the scope of these measures varied as a function of time (minutes, weeks) and spatial setting (i.e., smart phone vs. interview). Regarding reliability, acoustic features were temporally unstable until we specified the level of temporal/spatial resolution. Regarding validity, accuracy based on machine learning of acoustic features predicting SITB varied as a function of resolution. High accuracy was achieved (i.e., ~87%), but only when the acoustic and SITB measures were "temporally-matched" in resolution was the model generalizable to new data. Unlocking the potential of biobehavioral technologies for clinical psychiatry will require careful consideration of resolution.

Ambulatory digital phenotyping of blunted affect and alogia using objective facial and vocal analysis: Proof of concept.

Negative symptoms reflect one of the most debilitating aspects of one of the most debilitating diseases known to humankind. As yet, our treatments for negative symptoms are palliative at best and our understanding of their causes is relatively superficial. To address this, we are developing objective ambulatory tools for digitally phenotyping their severity which can be used outside the confines of the traditional clinical and research settings. The present study evaluated the feasibility, reliability and validity of ambulatory vocal acoustic and facial emotion expression analysis. Videos were provided by 25 patients with schizophrenia or schizoaffective disorder and 27 nonpsychiatric controls using inexpensive, non-invasive ambulatory recording methods. Controls provided 411 video recordings, and patients provided 377 video recordings; an average of 15.22 and 14.50 per participant per group respectively. The vast majority (over 80%) of these videos were usable for analysis. An empirically-supported, limited-feature vocal (7 features) and facial (3 features) set was examined. Within participants, these features varied considerably over time, but showed moderate to good test-retest reliability in many cases once contextual factors (e.g., activity involved in at the time of testing) were accounted for. Vocal and facial features showed statistically significant convergence with a "gold standard" negative symptom measure. Ambulatory vocal/facial features were more strongly associated with engagement in social or work activities in patients than negative symptom ratings. These data support the use of ambulatory vocal/facial analytic technologies for digital phenotyping of these negative symptoms.

Exploring the racial diagnostic bias of schizophrenia using behavioral and clinical-based measures.

There is evidence that African Americans are 2.4 times more likely to be diagnosed with a schizophrenia-spectrum diagnosis compared with White individuals, who are more likely to receive an affective diagnosis. The reason for these diagnostic discrepancies is unclear, however, 2 explanations have garnered attention: epigenetic differences and systematic error or bias in the diagnostic process. The latter is the focus of the present study and it is hypothesized that the bias involves cultural insensitivity on the part of the clinician. The present study has investigated bias-driven diagnostic disparities between African Americans and White individuals, by using traditional symptom rating scales, clinical diagnoses, and objective, behaviorally based measures. Data was aggregated from 3 separate studies conducted on outpatients (N = 251) with schizophrenia-spectrum or affective disorders. The present study used computationally derived acoustic markers of speech to tap hallmark negative symptoms (e.g., blunted affect or alogia) and behavioral-based markers of language failures to tap disorganization. Clinician symptom ratings were made using the Brief Psychiatric Rating Scale. Our findings confirmed the diagnostic bias between African Americans and White individuals though there were no differences on clinician symptom ratings. On the other hand, the computerized and behavioral measures revealed more speech disorder and less blunted affect in African Americans versus White individuals. Moderation analysis suggests that behaviorally based measures impact the relationship between race and diagnosis; however, this was largely unsupported for race and clinical symptom ratings. Further research is needed to disentangle normative variations from psychopathology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The importance of loneliness in psychotic-like symptoms: Data from three studies.

Poor social connection or loneliness is a prominent feature of schizotypy and may exacerbate psychosis risk. Previous studies have examined the inter-relationships between loneliness and psychosis risk, but critically, they have largely been conducted in non-clinical samples or exclusively used laboratory questionnaires with limited consideration of the heterogeneity within schizotypy (i.e., positive, negative, disorganized factors). The present study examined links between loneliness and psychotic-like symptoms across the dimensions of schizotypy through cross-sectional, laboratory-based questionnaires (Study 1; N = 160), ambulatory assessment (Study 2; N = 118) in undergraduates, and ambulatory assessment in inpatients in a substance abuse treatment program (Study 3; N = 48). Trait positive schizotypy consistently predicted cross-sectional and state psychotic-like symptoms. Loneliness, assessed via cross-sectional and ambulatory means, was largely linked with psychotic-like symptoms. Importantly, psychotic-like symptoms were dynamic: psychotic-like symptoms largely increased with loneliness in individuals with elevated positive and disorganized schizotypal traits, though there were some inconsistency related to disorganized schizotypy and state psychotic-like symptoms. Negative schizotypy and loneliness did not significantly interact to predict psychotic-like symptoms, suggesting specificity to positive schizotypy. Ambulatory approaches provide the opportunity for ecologically valid identification of risk states across psychopathology, thus informing early intervention.

Ambulatory vocal acoustics, temporal dynamics, and serious mental illness.

Acoustic analysis of vocal expression offers a potentially inexpensive, unobtrusive, and highly sensitive biobehavioral measure of serious mental illness (SMI)-related issues. Despite literature documenting its use for understanding SMI, prior studies have largely ignored that vocal expression is highly dynamic within individuals over time. We employed ambulatory vocal assessment from SMI outpatients to understand links between vocal expression, SMI symptoms, and affective states. Vocal samples were analyzed using a validated acoustic analysis protocol. Overall, vocal expression was not directly related to SMI symptoms but changed as a function of state and state by symptom interactions. The results suggest that (a) vocal expression fails to modulate across changing affective states in individuals with active SMI symptoms, (b) this lack of modulation may be commonly associated with many SMI symptoms, and (c) vocal analysis can accommodate temporal dynamics. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Targets for the Treatment of Insomnia in Veterans With Serious Mental Illness.

STUDY OBJECTIVES: Insomnia is pervasive among people with serious mental illnesses (SMI) and has a profound negative impact on their psychiatric symptom management and recovery. However, little is known about the factors that affect severity of insomnia in those with SMI. In addition, very few studies have explored whether evidence-based interventions developed for those without SMI are appropriate for or applicable to individuals with SMI. The purpose of this study was to test the role of arousal, dysfunctional cognitions about sleep, and sleep-related behaviors in predicting severity of insomnia in a sample of 60 Veterans who were receiving care in Veterans Health Administration mental health and psychosocial rehabilitation programs and who reported subjective insomnia. In addition, information was collected regarding the types of insomnia treatments provided to these Veterans. METHODS: Participants completed assessments of insomnia severity and sleep-related arousal, behaviors, and cognitions. Medical records were reviewed to determine whether participants had been screened/assessed for insomnia and whether treatments for insomnia were provided before the date of referral to the study. Multiple regression was used to predict insomnia severity on the basis of these factors. RESULTS: Most participants (81.7%) reported moderate to severe insomnia, although only 3.3% had a diagnosis of insomnia in their medical records. Worry and helplessness about sleep were predictive of insomnia severity; better self-reported sleep hygiene and higher levels of arousal were also associated with greater severity of insomnia. Education about sleep hygiene and medication were the only types of insomnia treatment received. CONCLUSIONS: Similar to insomnia among individuals without SMI, insomnia in Veterans with SMI is associated with dysfunctional sleep-related behaviors and cognitions. Many of the Veterans also lacked access to settings and resources conducive to healthy sleep. Veterans with SMI should be regularly assessed for insomnia. Research is needed concerning optimal evidence-based insomnia interventions for addressing behaviors and cognitions in this population in the context of these challenges.

Gender differences in antipsychotics prescribed to veterans with serious mental illness.

OBJECTIVE: To examine gender differences in prescribing of antipsychotic medications (APMs) according to their liability for weight gain and other metabolic side effects. METHOD: We identified 4510 patients with schizophrenia or bipolar disorders receiving usual care in a Veterans Affairs (VA) health care network in the U.S. mid-Atlantic region who initiated treatment with an APM between October 2006 and September 2011. We used multivariable logistic regression to examine gender differences in the likelihood of incident prescription of APMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and selected Veteran demographic, mental health and physical health characteristics. RESULTS: Overall, 58% of women were prescribed an APM with a low risk of metabolic side effects compared to 45% of men (P<.001). In multivariable analysis, women Veterans were 1.47 times as likely as men to be prescribed a low-metabolic-risk APM (95% confidence interval: 1.26-1.73, P<.001). Several demographic and clinical covariates were also independently related to prescribing of APMs by level of metabolic risk. CONCLUSIONS: The results may suggest that prescribing choices for APMs by VA mental health prescribers and female Veterans reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness.

BACKGROUND: Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system. METHODS: We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics. RESULTS: Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk. LIMITATIONS: This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made. CONCLUSIONS: Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Evaluation of quetiapine abuse and misuse reported to poison centers.

OBJECTIVE: There are case reports of abuse of quetiapine, but no studies address quetiapine abuse or misuse. Most literature on the population that abuses quetiapine describes an older age group with previous substance abuse history, many of whom are in jail. The objective of this study was to evaluate national poison center data on misuse/abuse of quetiapine. METHODS: A retrospective study of American Association of Poison Control Centers National Poison Data System data from 2005 to 2011 on single substance quetiapine exposures coded as intentional misuse or abuse and followed to known outcome was performed. Data were evaluated for age, toxicity, management sites, treatments, and medical outcomes. RESULTS: There were 3116 cases meeting inclusion criteria; reason was misuse in 1948 cases and abuse in 1168 cases. The median age was 23 years. Misuse was reported most often in adults, whereas abuse occurred most frequently in adolescents. The male-to-female ratio was 1.7 for abuse and 1.0 for misuse. There were no deaths. Moderate or major toxicity occurred in 23.7% and 27.1% of misuse and abuse cases, respectively. Seventy-six percent were treated in the emergency department and/or received medical admission. CONCLUSIONS: Misuse was more common than abuse, except in adolescents for whom abuse was more frequent. Although outcomes were generally good, significant toxicity occurred in 25% of cases and more than 75% of the patients were treated in the emergency department and/or received medical admission. The consequences of nonmedical use of quetiapine are serious in some patients.