Racial Differences in Mental Health Recovery among Veterans with Serious Mental Illness.

Black consumers with serious mental illness (SMI) face significant challenges in obtaining quality mental health care and are at risk for experiencing significant disparities in mental health care outcomes, including recovery from mental illness. Patient-provider interactions may partly contribute to this disparity. The purpose of the current study was to understand the effects of race, psychosis, and therapeutic alliance on mental health recovery orientation among Veterans with SMI. Participants were Veterans who had an SMI being treated at two Veteran Affairs outpatient mental health clinics by a psychiatrist or nurse practitioner. Participants completed the Behavior and Symptom Identification Scale (BASIS-24), Mental Health Recovery Measure, and patient-report Scale to Assess the Therapeutic Relationship (STAR-P) which includes three subscales: positive collaboration, positive clinician input, and non-supportive clinician input. Regression analyses were used to determine interactive effects of race, psychosis severity, and therapeutic alliance variables. The sample was 226 Veterans (50% black, 50% white). Black participants were slightly older (p < .05), had higher baseline psychosis (p < .05), higher mental health recovery (p < .05), and perceived less non-supportive clinician input (p < .01) than white participants. Regression analyses indicated a significant three-way interaction among race, psychosis, and positive collaboration (p < .01). Greater positive collaboration attenuated the negative effect of higher levels of psychosis on mental health recovery orientation for black participants. Conversely, for white participants, positive collaboration had little effect on the negative relationship between psychosis severity and mental health recovery orientation. Increased levels of psychosis may inhibit patients' perceptions of their ability to recover from SMI. However, for black participants, positive collaboration with mental health providers may moderate the effects of psychotic symptomatology.

Predictors of patient communication in psychiatric medication encounters among veterans with serious mental illnesses.

OBJECTIVE: Person-centered psychiatric services rely on consumers actively sharing personal information, opinions, and preferences with their providers. This research examined predictors of consumer communication during appointments for psychiatric medication prescriptions. METHODS: The Roter Interaction Analysis System was used to code recorded Veterans Affairs psychiatric appointments with 175 consumers and 21 psychiatric medication prescribers and categorize communication by purpose: biomedical, psychosocial, facilitation, or rapport-building. RESULTS: Regression analyses found that greater provider communication, symptomology, orientation to psychiatric recovery, and functioning on the Repeatable Battery for the Assessment of Neuropsychological Status Attention and Language indices, as well as consumer diagnostic label, were positive predictors of consumer communication, though the types of communication impacted varied. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Provider communication is the easiest variable to intervene on to create changes in consumer communication. Future research should also consider how cognitive and symptom factors may impact specific types of consumer communication in order to identify subgroups for targeted interventions. (PsycINFO Database Record

The interactive effects of negative symptoms and social role functioning on suicide ideation in individuals with schizophrenia.

Findings regarding the protective effect of social role functioning on suicide ideation in individuals with schizophrenia have been mixed. One reason for such inconsistencies in the literature may be that individuals with prominent negative symptoms of schizophrenia may not experience a desire for social closeness, and therefore social role functioning may not influence suicide risk in these individuals. The aim of this study was to examine the moderating effects of self-reported desire for social closeness and interviewer-rated negative symptoms on the relationship between social role functioning and suicide ideation. Our sample consisted of 162 individuals who had been diagnosed with schizophrenia-spectrum disorders; all participants completed self-report questionnaires and clinician-administered interviews, and moderation hypotheses were tested with a non-parametric procedure. The results indicated that motivation and pleasure-related negative symptoms moderated the relationship between social role functioning and suicide ideation; self-reported desire for social closeness and negative symptoms related to expression did not have such a moderating effect. Specifically, better social role functioning was associated with less suicide ideation only in those individuals who had low motivation and pleasure-related negative symptoms; no significant relationship was observed between social role functioning and suicide ideation among those with elevated motivation and pleasure-related negative symptoms. These findings suggest that assessing for negative symptoms and social role functioning may inform suicide risk assessments in individuals with schizophrenia, and improving social role functioning may reduce suicide ideation among those with few motivation and pleasure-related negative symptoms.

Access to and Use of the Internet by Veterans with Serious Mental Illness.

This study evaluated internet use among 239 veterans with serious mental illness who completed questionnaires assessing demographics and internet use in 2010-2011. The majority of individuals (70 %) reported having accessed the internet and among those, 79 % had accessed it within the previous 30 days. Those who were younger and more educated were more likely to have accessed the internet, as were those with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder, compared to individuals with PTSD. Veterans with serious mental illness commonly use the internet, including to obtain health information, though use varies across demographic characteristics and clinical diagnosis.

Social affiliation and negative symptoms in schizophrenia: Examining the role of behavioral skills and subjective responding.

Schizophrenia is characterized by profound impairment in the motivation for social affiliation. Negative symptoms are associated with such impairment but the contribution of behavioral skill deficits is unclear. In this study we utilized a novel video paradigm to assess performance-based affiliative behavioral skills in individuals with schizophrenia (N=48) and community controls (N=29). Individuals with schizophrenia displayed significant impairment in behavioral affiliative skills compared to controls; however, in response to the affiliative interaction the groups did not differ on self-reported affective responding, appraisal of the interaction partner, or desire to interact with the partner in the future. Importantly, within the patient group more severe negative symptoms (particularly those related to motivation and pleasure) were associated with poorer affiliative social skills and this relationship was independent of instrumental (non-social) skills, depression or positive symptoms. More severe negative symptoms were also associated with less positive affect in response to the interaction and less positive appraisals of the interaction partner. Self-reported social anhedonia was related to patients' diminished willingness to interact with the partner in the future. These results demonstrate that negative symptoms in schizophrenia are related to both affiliative skill deficits and less affiliative subjective responses to interaction partners.

Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship.

OBJECTIVE: Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of this study was to explore how dimensions of consumer preferences for shared decision making (i.e., preferences for obtaining knowledge about one's mental illness, being offered and asked one's opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. METHODS: Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. RESULTS: Preferences for involvement in treatment decisions was the unique component of shared decision making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive collaboration and prescriber input were associated with greater visit satisfaction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: When consumers with serious mental illnesses express preferences to be involved in shared decision making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers' interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision making should occur within the context of a strong therapeutic relationship.

Factors associated with shared decision-making preferences among veterans with serious mental illness.

OBJECTIVE: This study evaluated preferences for shared decision making with respect to mental health treatment in a sample of veterans who were diagnosed as having serious mental illness. METHODS: Participants were 239 outpatients receiving care from the Department of Veterans Affairs who completed self-report questionnaires assessing demographic factors, shared decision-making preferences, psychiatric symptom severity, and the therapeutic relationship with their second-generation antipsychotic prescribers (N=21). Preferences were assessed in regard to three components of decision making: knowledge about mental illness, options about mental health treatment, and decisions about mental health care. RESULTS: Most participants (85%) indicated that they preferred to be offered options and to be asked their opinions about mental health treatment. More variability was noted in preferences for obtaining knowledge and making final treatment decisions; 61% preferred to rely on their providers' knowledge and 64% preferred their provider to make treatment final decisions. Greater preferences for participation in shared decision making were found among African American clients, those currently working for pay, those with college or higher education, those with other than a schizophrenia spectrum diagnosis, and those who reported a poorer therapeutic relationship with their prescribers. CONCLUSIONS: The degree to which veterans with serious mental illness desired to participate in their mental health care differed in terms of the aspect of care and across demographic and clinical factors. A thorough assessment of shared decision-making preferences is an important component of recovery-oriented, client-centered care.

The Motivation and Pleasure Scale-Self-Report (MAP-SR): reliability and validity of a self-report measure of negative symptoms.

The Clinical Assessment Interview for Negative Symptoms (CAINS) is an empirically developed interview measure of negative symptoms. Building on prior work, this study examined the reliability and validity of a self-report measure based on the CAINS-the Motivation and Pleasure Scale-Self-Report (MAP-SR)-that assesses the motivation and pleasure domain of negative symptoms. Thirty-seven participants with schizophrenia or schizoaffective disorder completed the 18-item MAP-SR, the CAINS, and other measures of functional outcome. Item analyses revealed three items that performed poorly. The revised 15-item MAP-SR demonstrated good internal consistency and convergent validity with the clinician-rated Motivation and Pleasure scale of the CAINS, as well as good discriminant validity, with little association with psychotic symptoms or depression/anxiety. MAP-SR scores were related to social anhedonia, social closeness, and clinician-rated social functioning. The MAP-SR is a promising self-report measure of severity of negative symptoms.

Internalized stigma in schizophrenia: relations with dysfunctional attitudes, symptoms, and quality of life.

Internalized stigma refers to the process by which individuals with mental illness apply negative stereotypes to themselves, expect to be rejected by others, and feel alienated from society. Though internalized stigma has been hypothesized to be associated with maladaptive cognitions and expectations of failure, this relationship with dysfunctional attitudes has not been fully examined. In the present study, 49 individuals with schizophrenia or schizoaffective disorder completed the Internalized Stigma of Mental Illness Scale (ISMI; Ritsher et al., 2003) in addition to measures tapping defeatist performance beliefs, beliefs regarding low likelihood of success and limited resources, negative symptoms, depression, and quality of life. Consistent with prior research, internalized stigma was correlated with depression and quality of life but not with negative symptoms. Further, internalized stigma was correlated with both measures of dysfunctional attitudes. After controlling for depressive symptomatology, the relationship between internalized stigma and beliefs regarding low likelihood of success and limited resources remained significant, and though the correlation between defeatist performance beliefs and internalized stigma was no longer significant, it was of a similar magnitude. Overall, these data suggest that dysfunctional attitudes play a role in internalized stigma in individuals with schizophrenia, indicating a possible point of intervention.

Social anhedonia and affiliation: examining behavior and subjective reactions within a social interaction.

Social anhedonia is a promising indicator for the vulnerability towards developing schizophrenia-spectrum disorders and is an important determinant of the social impairment associated with these disorders. It is unknown if social anhedonia is associated with true deficits in experiential reactions or if lower social functioning in social anhedonia reflects behavioral deficits in social skill or initiation of social contact. Using a novel social interaction task, the current study compared controls (n=60) to individuals elevated on social anhedonia (n=49) on observer-rated social skill and facial affect and participant self-reports of their experiential reactions to an affiliative interaction. Compared to the control group, the social anhedonia group was rated as behaviorally less affiliative and less socially skilled during the affiliative interaction. In response to the social interaction, the social anhedonia group reported less change in positive affect, less willingness to engage in future social interactions with the interaction partner, and less positive reactions toward the interaction partner compared to controls. There were no group differences in facial displays of emotion. Using a standardized affiliative stimulus, it was demonstrated that individuals high in social anhedonia have alterations in both their social skill and in their self-reported experiential reactions during a social interaction.

Screening for negative symptoms: preliminary results from the self-report version of the Clinical Assessment Interview for Negative Symptoms.

Though negative symptoms in schizophrenia are associated with a host of deleterious outcomes (e.g., White et al., 2009), not all individuals with schizophrenia suffer from negative symptoms (e.g., Blanchard et al., 2005). Thus, methods to quickly screen and identify patients for more intensive clinical interview assessments may have significant clinical and research utility. The present study is a preliminary examination of the reliability and validity of a self-report version of the newly developed Clinical Assessment Interview for Negative Symptoms (CAINS; Blanchard et al., 2011; Forbes et al., 2010; Horan et al., 2011). The CAINS-SR is a 30-item self-report measure that assesses Experiential (avolition, anhedonia, asociality) and Expressive (blunted affect, alogia) domains of negative symptoms. Participants (N = 69) completed the CAINS-SR questionnaire and were evaluated with symptom interviews using the CAINS and other non-negative symptom interviews that assessed psychotic, affective, and other symptoms. The Experience subscale of the CAINS-SR demonstrated good internal consistency, convergent validity, and discriminant validity, while the poorer psychometric properties of the Expression subscale suggest that self-report of negative symptoms should focus on the experiential domain. Overall, preliminary findings indicate that the CAINS-SR (addressing experiential deficits) may be a useful complement to the clinician-rated interview measure. Future research on the sensitivity and specificity of the CAINS-SR will determine its suitability as a screening measure.