Ethnic, racial and cultural identity and perceived benefits and barriers related to genetic testing for breast cancer among at-risk women of African descent in New York City.

BACKGROUND: Due to disparities in the use of genetic services, there has been growing interest in examining beliefs and attitudes related to genetic testing for breast and/or ovarian cancer risk among women of African descent. However, to date, few studies have addressed critical cultural variations among this minority group and their influence on such beliefs and attitudes. METHODS: We assessed ethnic, racial and cultural identity and examined their relationships with perceived benefits and barriers related to genetic testing for cancer risk in a sample of 160 women of African descent (49% self-identified African American, 39% Black-West Indian/Caribbean, 12% Black-Other) who met genetic risk criteria and were participating in a larger longitudinal study including the opportunity for free genetic counseling and testing in New York City. All participants completed the following previously validated measures: (a) the multi-group ethnic identity measure (including ethnic search and affirmation subscales) and other-group orientation for ethnic identity, (b) centrality to assess racial identity, and (c) Africentrism to measure cultural identity. Perceived benefits and barriers related to genetic testing included: (1) pros/advantages (including family-related pros), (2) cons/disadvantages (including family-related cons, stigma and confidentiality concerns), and (3) concerns about abuses of genetic testing. RESULTS: In multivariate analyses, several ethnic identity elements showed significant, largely positive relationships to perceived benefits about genetic testing for breast and/or ovarian cancer risk, the exception being ethnic search, which was positively associated with cons/disadvantages, in general, and family-related cons/disadvantages. Racial identity (centrality) showed a significant association with confidentiality concerns. Cultural identity (Africentrism) was not related to perceived benefits and/or barriers. CONCLUSIONS: Ethnic and racial identity may influence perceived benefits and barriers related to genetic testing for breast and/or ovarian cancer risk among at-risk women of African descent. Genetic counseling services may want to take into account these factors in the creation of culturally-appropriate services which best meet the needs of this heterogenous population.

Psychosocial effects of enhanced external counterpulsation in the angina patient: a second study.

Enhanced external counterpulsation (EECP) is a noninvasive technique that has shown promise in the treatment of ischemic coronary artery disease. Patients undergoing EECP were tested for alterations in psychosocial state associated with treatment. Overall perception of health and quality of life improved with EECP. There was also significant improvement in levels of depression, anxiety, and somatization but no change in levels of anger or hostility. On most measures, change was more significant for subjects who showed objective evidence of resolution of ischemia. Given the known predictive relationship between depression and mortality from cardiac disease, the improvement in depression scores through EECP indicates a finding of potential importance that may warrant further study in future research.

Social class of origin and cardinal symptoms of schizophrenic disorders over the early illness course.

BACKGROUND: This study describes the relationship of social class of origin to cardinal symptoms of schizophrenic disorders over the early illness course. METHOD: The sample of subjects was drawn from the Suffolk County Mental Health Project, a longitudinal epidemiologic study of first-hospitalized subjects with psychotic disorders; the present study focused on patients with schizophrenic disorders. At baseline, subjects were dichotomized into upper/middle and lower social class of origin groups, based on occupation of the head of the household of origin. The patients in both groups were assessed for the major symptoms of schizophrenic disorders using standard structured instruments at both baseline and 6-month follow-up. The 6-month symptom severity levels were compared between the groups, controlling for baseline symptom status and potential confounders. RESULTS: At 6-month follow-up, the upper/middle social class of origin group, as compared to the lower social class of origin group, had lower symptom levels for hallucinations (adjusted OR = 4.88, chi2 = 8.49, P = 0.004) and delusions (adjusted OR = 2.46, chi2 = 4.16, P = 0.04). There were no notable group differences for any of the negative or thought disorganization symptoms. CONCLUSIONS: Social class of origin is associated with positive symptoms of schizophrenia over the early illness course.

Conduct disorder and mania: what does it mean in adults.

OBJECTIVE: Because of the relationship between childhood behavior disorders and adult substance abuse, we hypothesized that substance abusing adult bipolars were more likely to have had behavior disorders as children than nonabusing bipolar adults. METHODS: Conduct disorder (CD) symptoms in 132 bipolar adults were compared by age and presence of comorbid substance use problems using data from the Epidemiologic Catchment Area study. RESULTS: Rates of CD were higher in bipolar subjects under age 30 (32.6%) versus those over (16.3% P<0.05). Young BPs with substance use problems (SUBST) had CD rates three times those without SUBST (52% vs. 14.8%) (P < 0.01). Young subjects without mania or SUBST had CD rates of 7.75%. CONCLUSION: Substance abuse in bipolar adults may be more related to childhood conduct disorder than uncomplicated bipolar disorder.

Homelessness among individuals with psychotic disorders hospitalized for the first time: findings from the Suffolk County Mental Health Project.

OBJECTIVE: Although data suggest that homelessness among persons with severe mental disorders is both distressing and common, several important epidemiologic questions remain unanswered. This study reports on the occurrence of homelessness in a quasi-representative sample of persons newly hospitalized with psychotic disorders. The authors also compared rates of homelessness in different diagnostic groups and among groups with differing symptom profiles. METHOD: The study was based on data from 237 first-admission patients hospitalized at 10 of the 12 inpatient facilities in eastern Long Island, N.Y. Consensus diagnoses were derived from multiple sources of information, including the Structured Clinical Interview for DSM-III-R. Patients were followed over a 24-month period after initial interview. Homelessness histories were based on subject self-reports. RESULTS: Fifteen percent of the patients had experienced at least one episode of homelessness before or within 24 months of their first psychiatric hospitalization. In more than two-thirds of these cases, the initial homeless episode had occurred before the first hospitalization. There were no significant differences in the risk of homelessness among diagnostic groups. Among subjects diagnosed with schizophrenia and related disorders, those with high levels of negative symptoms had a significantly greater risk of prehospitalization homelessness than those with low symptom levels. CONCLUSIONS: The high rate of homelessness observed must be viewed with profound concern by clinicians, consumers, and policymakers alike. The findings support the importance of intervening early in the course of disorder, particularly for persons diagnosed with psychotic illnesses.

Diagnosis, treatment, and six-month outcome status in first-admission psychosis.

Six-month outcome status was examined in 202 first-admission inpatients with DSM-III-R schizophrenia spectrum (N = 96), psychotic bipolar disorder (N = 64), and psychotic depression (N = 42) drawn from 10 facilities in Suffolk County, New York. Schizophrenics fared significantly worse on all outcome variables rehospitalization, which ranged from 17.7 to 23.4%. Bipolars had good psychosocial outcomes regardless of clinical outcome, while the two outcome domains were uncorrelated among schizophrenics and psychotic depressed. Schizophreniform patients had significantly better outcome than those with schizophrenia or schizoaffective disorder. Posthospital treatment was generally unrelated to outcome except that fewer rehospitalized schizophrenics received continuous treatment, and patients with psychotic depression with poorer psychosocial outcome received medication less frequently. These findings highlight the different treatment needs of these diagnostic groups, especially as regards the provision of more intensive rehabilitation for schizophrenic patients and the "poor-outcome" psychotic depressed.

HIV infection among young adults with psychotic disorders.

OBJECTIVE: The authors examined HIV infection among young adults with newly diagnosed psychotic disorders. METHODS: The study was based on a research cohort of 320 first-admission patients aged 20-39 years in a semirural-suburban county. Research assessments and medical records were systematically reviewed for information about HIV status. RESULTS: Despite the fact that few patients were tested for HIV, 12 (3.8%) of the 320 patients had a known HIV infection. In all 12 cases, the HIV infection was contracted before the onset of psychosis. AIDS was the leading cause of mortality in the 320 patients. CONCLUSIONS: The HIV epidemic may be having an important effect on the etiology and the course of psychotic disorders.

Substance use disorder and the early course of illness in schizophrenia and affective psychosis.

The relationship between a history of substance use disorder and the early course of psychotic illness was examined in 96 subjects with schizophrenia and 106 subjects with affective psychosis followed in the Suffolk County Mental Health Project, a longitudinal study of first-admission psychosis. Subjects received a structured diagnostic interview and clinical ratings at baseline assessment and again 6 months later. The 6-month assessment included information about treatment received during the interval. A lifetime history of substance use disorder was associated with worse clinical functioning at 6 months for schizophrenia subjects, but not for those with affective psychosis. There were no significant associations of substance use disorder with type of treatment during the interval or with self-reported compliance with medication. Schizophrenia subjects were more likely than subjects with affective psychosis to report cannabis use during the interval and to meet criteria for cannabis use disorder.

Insight in first-admission psychotic patients.

BACKGROUND: The prevalence of insight was examined longitudinally in psychotic patients with schizophrenia (n = 86), bipolar disorder (n = 52), major depressive disorder (n = 35) and other psychoses (n = 16). METHOD: Before discharge and at 6-month follow-up, insight in first-admission patients from 10 facilities in Suffolk County, New York was rated as part of a modified Hamilton Depression Scale. RESULTS: Initially, 80% of depressives but approximately half with other diagnoses manifested insight. At follow-up, most patients demonstrated insight except for the schizophrenic patients. After controlling for diagnosis, significant correlates of baseline insight were being married, hospitalized in a community or academic facility, intelligence and negative symptoms. At follow-up, after controlling for diagnosis and baseline insight, prior treatment was predictive. This finding held for schizophrenic patients separately. CONCLUSION: Lack of insight is more prevalent in schizophrenia and improves over time. The components of prior treatment leading to better insight should be explored.

The Suffolk County Mental Health Project: demographic, pre-morbid and clinical correlates of 6-month outcome.

The diagnostic specificity and predictive utility of the classical prognostic indicators in schizophrenia were examined in psychotic patients enrolled in the Suffolk County Mental Health Project. First-admission psychotic patients with schizophrenia (N = 96), major depression (N = 42), and bipolar disorder (N = 64) drawn from 10 facilities in Suffolk County, New York, were assessed during their initial hospitalization and at 6-month follow-up. Longitudinal consensus diagnoses were determined after the 6-month interview. The diagnostic groups shared similar background characteristics, but schizophrenics had poorer pre-morbid adjustment, longer periods of psychosis before hospitalization and more negative symptoms initially. Except for rehospitalization, schizophrenics had the worst and bipolars the best functioning at follow-up. Among the classical prognostic indicators, the best predictor of 6-month outcome for each diagnostic group was premorbid functioning.

Felbamate-induced headache.

We prospectively investigated drug-induced headaches (HA) among 60 epileptic patients receiving felbamate (FBM). Twenty patients (33%) experienced HA. HA was pounding in 11 (55%), steady in 9 (45%), moderate or severe in 19 (95%), occurred at least once a week in all patients, and was relieved by nonnarcotic analgesics in 14 (70%). Mean duration on FBM before HA onset was 19 days. HA occurred with higher FBM doses and was relieved in 8 of 13 patients (62%) with FBM dose reduction. FBM was discontinued in most cases because of risks of anemia or hepatitis; not because of HA. Other side effects included insomnia (25%), gastrointestinal symptoms (27%), and agitation or restlessness (23%). HA is a common dose-related complication of FBM, occurs early after initiation of FBM treatment, and is relieved by dose reduction.

Surgical anticipatory stress manifests itself in immunocyte desensitization: evidence for autoimmunoregulatory involvement.

The immunocyte behavior (conformational changes and locomotion in response to signal molecule challenge) in patients about to undergo elective cardiac surgery was studied to elucidate the effect of psychological anticipatory stress on the immune system. Granulocytes and monocytes from 10 patients and 35 non-surgical controls were examined. Computer-assisted microscopic image analysis, capable of measuring cellular conformational and velocity changes, was used to measure the responsiveness of these immunocytes to peptidergic and cytokine stimulation. Immunocyte desensitization would appear to account for the reduction in their abilities to respond to chemotaxic challenge associated with the pre-cardiac surgery state. Their abilities to respond to D-Ala2-Met-enkephalinamide (DAMA) were observed only at much higher concentrations than previously reported (10-11 M vs. 10-9 M prior to surgery). This finding, together with the observed decrease in adrenocorticotropin levels compared to non-surgical controls, suggests that neutral endopeptidase activity was elevated just prior to surgery. Indeed, neutral endopeptidase activity is statistically elevated in the pre-cardiac surgery state. Furthermore, glucocorticoid levels remained constant, within normal resting limits, in both groups. Thus, surgical anticipatory stress may manifest itself, in part, as a desensitization of various immunocytes. Thus, a psychological anticipatory stress response may be a precipitant of the desensitization. Although this desensitization seemed not to involve the entire hypothalamic-pituitary-adrenal axis, the data suggest that psychological anticipatory stress may initially involve and influence autoimmunoregulation.

Mood-congruent versus mood-incongruent psychotic symptoms in first-admission patients with affective disorder.

The distribution of mood-congruent and mood-incongruent symptoms in 49 first-admission DSM-III-R psychotic bipolar and 35 psychotic depressed patients is presented. Most patients had mood-incongruent symptoms (77.4%). 73% of mood-incongruent bipolars and 32% of incongruent depressives had a combination of mood-congruent and mood-incongruent symptoms. Demographic and clinical variables were unrelated to incongruence. The only 24-month clinical outcome predicted by mood incongruence was poorer GAF rating. 15 of the 16 patients whose diagnosis was changed at follow-up from affective to nonaffective psychosis had mood-incongruent features initially. The findings raise questions about the general prognostic utility of mood congruence.

Epidemiology, diagnosis, and course of brief psychoses.

OBJECTIVE: This study investigated acute and nonacute brief psychoses. On the basis of previous work, the authors proposed that 1) acute brief psychoses occur predominantly in females, 2) they often do not conform to the diagnoses of DSM-III-R, 3) they are temporally stable, and 4) nonacute brief psychoses do not share these distinctive features. METHOD: The data are from a follow-up study of 221 first-admission patients with affective and nonaffective psychoses. Patients were given extensive assessments at initial evaluation, 6-month follow-up, and 24-month follow-up. The research team made consensus ratings of the presence of psychosis, DSM-III-R diagnosis, mode of onset of disorder, and course of disorder. Brief psychoses were defined by a diagnosis of nonaffective psychosis at the initial evaluation and a rating of full remission at 6-month follow-up; acute brief psychoses met the additional criterion of acute onset as defined by ICD-10. RESULTS: Twenty (9%) of the 221 psychoses were brief psychoses. Only seven (3%) were acute brief psychoses, but among these, six occurred in women, five were undiagnosable, and none had evolved into an affective disorder or a chronic disorder by the time of the 24-month follow-up. The 13 nonacute brief psychoses did not exhibit distinctive features, and five of them later evolved into chronic disorders. CONCLUSIONS: Acute brief psychoses emerged as a highly distinctive and temporally stable form of psychosis that may merit a separate diagnostic classification. The more numerous nonacute brief psychoses may represent mild forms of nonaffective psychoses such as schizophrenia.

Fatigue therapy in multiple sclerosis: results of a double-blind, randomized, parallel trial of amantadine, pemoline, and placebo.

OBJECTIVE: To determine the relative efficacy of amantadine, pemoline, and placebo in treatment of multiple sclerosis (MS)-related fatigue. BACKGROUND: Fatigue is a complication of MS. Both pemoline and amantadine have been used to treat MS fatigue, but their relative efficacy is not known. METHODS: Amantadine, pemoline, and placebo were compared in a randomized, double-blind, placebo-controlled study using a parallel-group design. Ninety-three ambulatory MS patients completed the study. Primary outcome measures were the fatigue severity scale (FSS); the MS-specific fatigue scale (MS-FS); and subjective response determined by verbal self-report. Secondary outcome measures consisted of assessments of sleep, depression, and vitality. Repeated-measures analysis of variance with planned post-hoc contrasts and Fisher's exact test were used to compare treatment response. RESULTS: Amantadine-treated patients showed a significantly greater reduction in fatigue, as measured by the MS-FS, than did patients treated with placebo (p = 0.04). By verbal report at the end of the study, 79% of patients treated with amantadine versus 52% treated with placebo and 32% treated with pemoline preferred drug therapy compared with no treatment (p = 0.03). No significant differences in any primary outcome measures were noted between pemoline and placebo. Neither amantadine nor pemoline affected sleep or depression relative to placebo. CONCLUSION: Amantadine was significantly better than placebo in treating fatigue in MS patients, whereas pemoline was not. The benefit of amantadine was not due to changes in sleep, depression, or neurologic disability.

Bizarre delusions and first-rank symptoms in a first-admission sample: a preliminary analysis of prevalence and correlates.

This report examines the prevalence and correlates of bizarre delusions and Schneider's first-rank symptoms (FRS) in a first-admission sample with psychosis. A total of 196 patients were assessed with the Structured Clinical interview for DSM-III-R (SCID) and given a consensus diagnosis. Project psychiatrists blind to the consensus diagnoses coded each delusion and hallucination in the sample for both FRS and DSM-III-R bizarreness. Interrater reliability of bizarreness was lower than that of FRS (kappa = .681 v 861). The majority of symptoms (72%) were neither bizarre nor FRS, and of the remainder, bizarre delusions that were not also FRS were extremely uncommon. The prevalence of FRS was 70% in schizophrenia, 29% in psychotic bipolar disorder, and 18% in psychotic depression. For seven schizophrenic patients (7.45%), diagnosis of that disorder depended on the presence of a DSM-III-R bizarre delusion to meet criteria. There was a trend for FRS to be associated with poorer prognostic features in the schizophrenic sample. We concluded that although the constructs of bizarre delusions and FRS overlap, FRS were a more important feature in schizophrenia than bizarreness. The rarity of bizarre delusions that were not FRS, combined with the lower reliability of their assessment as compared with that of FRS, raises questions about the continued emphasis on this phenomenon in the definition of schizophrenia.

Psychosocial effects of enhanced external counterpulsation in the angina patient.

Enhanced external counterpulsation (EECP) is a noninvasive pantaloon device designed to increase coronary artery flow in the treatment of angina. This pilot study, conducted in 1992-1993, which used psychosocial testing pre- and posttreatment, yielded data suggesting that EECP is well tolerated psychosocially and produces improvement in the anginal syndrome. More comprehensive research is under way to test these preliminary conclusions.

Medication treatment in first-admission patients with psychotic affective disorders: preliminary findings on research-facility diagnostic agreement and rehospitalization.

The discharge medications of 101 Suffolk County subjects with facility and/or research diagnoses of affective disorder were ascertained. Rehospitalization was recorded for a 6-month follow-up period. Twenty-three of 31 patients (74.2%) with a facility diagnosis of depressive disorder were prescribed antidepressants, and 21 of 36 patients with a facility diagnosis of bipolar disorder (58.3%) were prescribed lithium. When research and facility diagnoses concurred, 84.2% of depressed patients were prescribed antidepressants, and 66.7% of bipolars were given lithium. The percentages were lower when the two diagnoses were discrepant. The results for diagnostic congruence were independent of demographic variables, length of stay, and premorbid functioning. Patients prescribed diagnosis-specific medications had a lower rate of rehospitalization (7.3%) than those not prescribed such medications (22.2%). The findings suggest that such medications are prescribed in the more unambiguous cases of affective disorders and are important (with or without antipsychotic treatment) in preventing rehospitalization.

Psychotic patients with unclear diagnoses. A descriptive analysis.

This report describes the clinical characteristics of psychotic patients who received a 6-month longitudinal research diagnosis of psychosis not otherwise specified (NOS) or for whom no consensus diagnosis was reached. The reasons why these subjects could not be classified into a specific DSM-III-R category, their classification under the proposed DSM-IV criteria, their reclassification at 24-month follow-up, and differences between these groups and patients with schizophrenia and affective disorders in demographic characteristics, initial clinical features, and short-term course are explored. Data were drawn from the first phase of the Suffolk County Mental Health Project. Longitudinal consensus procedures were used to derive 6- and 24-month DSM-III-R diagnoses based on information from a structured diagnostic interview, an interview with the patient's clinician, the medical record and discharge summary, and significant others. Thirteen subjects (4.7%) received a diagnosis of psychosis NOS, and 12 (4.3%) had no consensus diagnosis. Seven with psychosis NOS had an acute onset with rapid remission; this subgroup met DSM-IV criteria for brief psychosis without stressors. As a group, the psychosis NOS subjects were significantly older and had a lower rate of lifetime alcohol abuse/dependence than the schizophrenic and affective disorder groups. Their short-term course was significantly better than that of the schizophrenics and similar to that of patients with an affective disorder. Subjects with no consensus diagnosis were more likely to have lifetime drug abuse/dependence than the other two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Interrater and observer/self-report correlation of psychopathology in routine clinical practice.

Interrater (attending vs resident) and observer/patient self-report correlations were assessed for 17 and 9 symptom factors, respectively, in a consecutive sample of psychiatric outpatients at the time of intake evaluation in a university based clinic using the Hopkins Psychiatric Rating Scale (HPRS) and the SCL-90R. Highly significant interrater reliability was obtained for most items on the HPRS but observer/self-report correlations were more variable, ranging from good (r = .60 to .75) for depression and phobic anxiety, to poor (r < .40) for obsessive-compulsive, paranoia, and psychoticism symptoms. Results also varied by patient sex. The findings suggest a role for both observer and, for specific symptoms, self-report symptom scales in routine clinical practice.