Comparison of medical treatment of patients with schizophrenia in general practitioners' clinics versus mental health clinics: A cohort study.

OBJECTIVES: Individuals with schizophrenia have more cardiometabolic comorbidities than the general population, live about twenty years less and consume more medical services. They are treated at general practitioners' clinics (GPCs) or at mental health clinics (MHCs). In this cohort study we investigated the association between patients' main treatment setting, cardiometabolic comorbidities and medical services utilization. METHODS: Demographics, healthcare services utilization, cardiometabolic comorbidities and medication prescriptions of patients with schizophrenia were retrieved from an electronic database for the period 1.1.2011 to 31.12.2012 and compared between patients treated mostly in MHCs (N = 260) and those treated mostly in GPCs (N = 115). RESULTS: GPC patients tended to be older (mean age 39.8 ± 13.7 vs. 34.6 ± 12.3 yrs., p < 0.0001), of lower socioeconomic status (42.6% vs 24.6%, p = 0.001) and have more cardiometabolic diagnoses (hypertension: 19.1% vs 10.8%, diabetes mellitus: 25.2% vs 17.0%, p < 0.05) than MHC patients. The former received more cardiometabolic disorder medications and utilized more secondary and tertiary medical services. Charlson Comorbidity Index (CCI) was higher in the GPC group than in the MHC group (1.8 ± 1.9 vs.1.2 ± 1. 6, p < 0.0001). A multivariate binary logistic regression analysis, adjusted for age, sex, SES and CCI found lower adjusted odds ratio for the MHC group versus the GPC group, of visiting an EMD, a specialist or to be hospitalized. CONCLUSIONS: The current study highlights the critical importance of integrating GPCs and MHCs, thus offering patients combined physical and mental care at a single location. More studies on the potential benefits of such integration to patients' health are warranted.

Adherence of patients with schizophrenia to hypothyroidism treatment.

Adherence to prescription medications is critical for both remission from schizophrenia and control of physical comorbidities. While schizophrenia with comorbid hypothyroidism is common, there is little research on adherence to hypothyroidism treatment in this population. The current study used a retrospective, matched case-control design. The cohort included 1,252 patients diagnosed with schizophrenia according to ICD-10 and 3,756 controls matched for gender, age, socioeconomic status and ethnicity without diagnosis of schizophrenia. All data were retrieved from the electronic medical database of a large health maintenance organization. Retrieved data included demographics, thyroid functionality test results and prescribed medications. Measures of adherence to therapy were used for analyses as were data from follow-ups of patients with hypothyroidism. A diagnosis of hypothyroidism was found in 299 patients, 115 of whom were also diagnosed with schizophrenia. The 184 without schizophrenia constituted the control group. No statistically significant differences were found between the two groups regarding prescriptions for L-thyroxin and TSH levels and number of TSH tests. Adherence of patients with schizophrenia to hypothyroidism treatment was found to be as good as that of individuals without a schizophrenia diagnosis.

Comorbid major depressive disorder in cognitive-behavior group treatment for social anxiety disorder: An examination of processes of symptom change.

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms and approximately 50% also meet criteria for major depressive disorder (MDD; Beesdo et al., 2007). In the present study, we examined the relationship between social anxiety and depressive symptoms during cognitive-behavior group treatment (CBGT) for SAD. Specifically, we compared individuals with SAD and comorbid MDD and individuals with SAD without MDD to examine the role of MDD as a moderator of social anxiety-depression relationship. Participants were 90 individuals seeking treatment for SAD (36% were diagnosed with MDD), who completed self-report measures of social anxiety and depression every 2 weeks during CBGT. Lower level mediational modeling indicated that for individuals without MDD, a reciprocal relationship was observed in which changes in both social anxiety and depressive symptoms mediated changes in each other. However, changes in social anxiety explained all subsequent changes in depression, whereas changes in depression explained 11.26% of subsequent changes in social anxiety. For individuals with both SAD and MDD, neither social anxiety nor depression significantly mediated changes in each other. Our findings suggest that different processes of change occur for individuals with and without MDD and clinical implications of these findings are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attenuated Access to Emotions in Obsessive-Compulsive Disorder.

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) posits that OCD is associated with attenuated access to internal states. Here we explored the implications of this model in the realm of emotions. Participants with OCD, anxiety disorders, and nonclinical control participants completed the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT), assessing two domains of emotional intelligence: Experiential emotional intelligence (EI), reflecting the ability to perceive and feel emotions accurately, and Strategic EI, reflecting the ability to understand and manage emotions correctly. As only Experiential EI requires accurate perception of one's emotions for adequate performance, we predicted an interaction between group and EI area. Specifically, we predicted that compared to both anxiety disorders and healthy control participants, OCD participants would show a larger deficit in Experiential area of the MSCEIT relative to the Strategic area. Results were fully in line with this prediction. Moreover, supporting the specificity of the hypothesized deficit to OCD, participants with anxiety disorders did not differ from nonclinical control participants in their performance, and findings were not attributable to anxiety or depression levels. These results replicate and extend previous findings obtained with analogue samples and suggest that OCD is associated with attenuated access to emotional states, which may be partially compensated for by reliance on semantic knowledge of emotion.

Thyroid function assessment before and after diagnosis of schizophrenia: A community-based study.

Alterations in thyroid hormone levels may affect brain and mental disorders. Conversely, schizophrenia and its antipsychotic treatments can affect thyroid hormone levels. However, data on thyroid hormone levels during the course of schizophrenia disorder are scant. The aim of the study was to assess the rate of thyroid hormone disorders in outpatients before and after diagnosis of schizophrenia. A retrospective matched-control design was used. The cohort included 1252 patients suffering from ICD-10 schizophrenia, and 3756 control subjects matched for gender, age, socioeconomic status, and origin. All were identified from the database of a large health management organization. The pertinent clinical data were collected from the electronic medical records. There was no significant between-group difference in the distribution of thyroid-stimulating hormone levels. Before diagnosis, both groups had a similar rate of hypothyroidism. After diagnosis of schizophrenia and initiation of antipsychotic treatment, the rate of hypothyroidism was significantly higher in the patient group. It remained significantly higher after exclusion of patients receiving lithium. The increased rate of hypothyroidism in patients with schizophrenia after, but not before, the diagnosis of schizophrenia suggests that antipsychotic medications may affect thyroid hormone levels. Screening for thyroid disorders is warranted in patients with schizophrenia under antipsychotic treatment.

Attention bias modification augments cognitive-behavioral group therapy for social anxiety disorder: a randomized controlled trial.

BACKGROUND: Cognitive-behavioral group therapy (CBGT) is a first-line treatment for social anxiety disorder (SAD). However, since many patients remain symptomatic post-treatment, there is a need for augmenting procedures. This randomized controlled trial (RCT) examined the potential augmentation effect of attention bias modification (ABM) for CBGT. METHODS: Fifty patients with SAD from three therapy groups were randomized to receive an 18-week standard CBGT with either ABM designed to shift attention away from threat (CBGT + ABM), or a placebo protocol not designed to modify threat-related attention (CBGT + placebo). Therapy groups took place in a large mental health center. Clinician and self-report measures of social anxiety and depression were acquired pre-treatment, post-treatment, and at 3-month follow-up. Attention bias was assessed at pre- and post-treatment. RESULTS: Patients randomized to the CBGT + ABM group, relative to those randomized to the CBGT + placebo group, showed greater reductions in clinician-rated SAD symptoms post-treatment, with effects maintained at 3-month follow-up. Group differences were not evident for self-report or attention-bias measures, with similar reductions in both groups. Finally, reduction in attention bias did not mediate the association between group and reduction in Liebowitz Social Anxiety Scale Structured Interview (LSAS) scores. CONCLUSIONS: This is the first RCT to examine the possible augmenting effect of ABM added to group-based cognitive-behavioral therapy for adult SAD. Training patients' attention away from threat might augment the treatment response to standard CBGT in SAD, a possibility that could be further evaluated in large-scale RCTs.

Mortality, morbidity and medical resources utilization of patients with schizophrenia: A case-control community-based study.

Patients with schizophrenia have higher level of mortality and physical comorbidity compared to control population. However the association to primary-, secondary- and tertiary-medical resources utilization is not clear. We used a retrospective community-based cohort of patients with schizophrenia (n=1389; age 37.53 years, 64.3% males) and, age-, gender-, and socioeconomic status-matched controls (n=4095; age 37.34 years; 64.3% males) who were followed-up for nine years. Mortality rate of patients was almost twice as high as that of matched controls (7% versus 3.8%). Diagnoses of ischemic heart disease and hypertension were more prevalent among controls than patients (8.2% versus 5%, and 21.6% versus 15.8%, respectively). Tertiary medical resources utilization was higher among patients with schizophrenia than control population (mean hospital admissions per year: 0.2 versus 0.12, emergency department visits: 0.48 versus 0.36). Patients that died were more likely to have cardiovascular disease, to be admitted to general hospital and to spend more days in hospital than patients that did not die. There is a discrepancy between lower rates of cardiovascular disease diagnoses but higher rates of mortality and tertiary medical resources utilization among patients with schizophrenia when compared to control population. This may stem from an under-diagnosis and, eventually, under-treatment of these patients.

Nonfunctional Redundant Acts Characterize OCD, Even in OCD-Unrelated Tasks: A Demonstration in Questionnaire Completion.

BACKGROUND: Ethological methods used to analyze human obsessive-compulsive disorder (OCD) rituals demonstrated excess of unnecessary repetitions as well as irrelevant, idiosyncratic acts (additions) compared to normal activity. A question that still remains is whether these well-known repetitions and additions are manifested in behaviors unrelated to the OCD rituals. Our objectives were to: (1) assess whether OCD-related repetitions and additions as found in previous studies also affect the patients' activity of filling out questionnaires and (2) evaluate the specificity of these behaviors to OCD as opposed to other anxiety disorders and healthy controls. SAMPLING AND METHODS: Several standardized disorder-specific self-report questionnaires were used in order to assess the patient's psychopathologies. The style of filling-out these questionnaires by OCD and non-OCD anxiety outpatients and normal controls was analyzed. Four categories were used: omissions, repetitions, corrections, and additions. RESULTS: The OCD group scored significantly higher on the number of additions as compared with both the anxiety group and the nonclinical group, and significantly higher on the number of corrections and repetitions as compared with the nonclinical group. CONCLUSIONS: The hallmarks of OCD, repetitions and additions, are manifested not only in the patient's rituals and thoughts, but in apparently "neutral" tasks that do not a priori involve the intrusive thoughts, urges, and images typical of obsessive-compulsive behavior. Additions seem to be more specific to OCD than repetitions. These two executive faults impede routine functionality of OCD patients in tasks related and unrelated to their rituals. Our study delineates simple, observable behavioral characteristics that distinguish between OCD and non-OCD anxiety patients as well as healthy individuals. These symptomatic behaviors may offer a clue to personality traits or deficits in executive functions that possibly play a part in the pathophysiology of OCD. Our results are an additional indication that nonfunctionality in obsessive-compulsive behavior deserves full attention for a better understanding of the psychopathological mechanisms of OCD.

Explicit and implicit self-evaluations in social anxiety disorder.

Cognitive models of social anxiety disorder (SAD) emphasize the role of explicit and implicit self-evaluations (SEs) in the etiology and maintenance of this condition. Whereas individuals with SAD consistently report lower explicit SEs as compared with nonanxious individuals, findings concerning implicit SEs are mixed. To gain a more nuanced understanding of the nature of SEs in SAD, we examined explicit and implicit SEs in two significant interpersonal domains: social rank and affiliation. Consistent with cognitive theorizing, we predicted that, compared to nonclinical controls (NCCs), individuals with SAD would exhibit lower explicit and implicit SEs in both domains. Guided by evolutionary theories we also predicted that the differences in SEs between the groups would be greater in the social rank, as compared to the affiliation, domain. Individuals diagnosed with SAD (n = 38) and NCCs) n = 40) performed two variants of the Self Implicit Association Test: one concerning social rank, and the other concerning affiliation. They also rated themselves on social-rank and affiliation traits. We found that, as compared to NCCs, individuals with SAD exhibited lower social-rank and affiliation SEs. Moreover, differences between the groups in social-rank SEs were greater than in affiliation SEs. Importantly, this pattern was evident in implicit SEs, as much as in explicit SEs. Our findings dovetail with evolutionary accounts highlighting the centrality of the social-rank system in SAD, and refine central tenets of cognitive theories of SAD. A multidomain, multimethod approach to the understanding of the self may broaden our conceptualization of SAD and related disorders. (PsycINFO Database Record

The association between serum creatine kinase, mood and psychosis in inpatients with schizophrenia, bipolar and schizoaffective disorders.

Previous studies demonstrated levels of serum CK (sCK) in the majority of patients undergoing acute psychosis. Records of 1054 patients hospitalized in Geha Mental Health Center during the study period were analyzed. Of them, 743 have been diagnosed with schizophrenia (Sz), 170 with schizoaffective disorder (SzA), and 158 with bipolar disorder (BP-I). Baseline sCK and PANSS values were obtained from each patient upon admission. Our results show that LnsCK is higher in patients with BP-I in comparison with patients with SZ, but not significantly different compared to patients with SzA. A multivariate analysis using linear regression model in which LnsCK was predicted by factors such as PANSS-total and sub-scores, IM injection, BMI, gender, and age among patients at each admission, revealed that PANSS-depression was inversely associated with LnsCK level in SzA and BP-I and not in SZ. A positive association was found between PANSS-total and sCK in SzA and BP-I; however, PANSS-positive scores correlated with sCK only in SzA. After controlling for confounders, it seems that sCK level is associated with the both affective and psychotic components. Serum CK may serve as a biomarker for affective exacerbation rather than psychosis.

Methadone treatment, bruxism, and temporomandibular disorders among male prisoners.

There is little information on bruxism related to illicit drug use. Prolonged drug use may damage the stomatognathic system via oral motor overactivity. The aim of the present study was to compare the rates of bruxism and temporomandibular disorders (TMDs) between prisoners with and without drug-use disorders, to evaluate the association between methadone treatment and bruxism and to assess the possible relationship between bruxism and pain. The sample included 152 male prisoners, 69 of whom were drug users maintained on methadone. All prisoners were examined by an experienced dentist and completed a questionnaire on their oral habits, with the aim of detecting signs or symptoms of TMD and/or bruxism. Additional data were collected from medical files. The prevalence of sleep bruxism and awake bruxism, but not of TMDs, was significantly higher among drug-user than non-drug user prisoners (52.2% vs. 34.9% for sleep bruxism, 59.7% vs. 30.1% for awake bruxism, and 46.3% vs. 25.6% for TMDs, respectively). Participants with awake bruxism were statistically more sensitive to muscle palpation compared with participants with sleep bruxism [rating scores (mean ± SD): 0.32 ± 0.21 vs. 0.19 ± 0.28, respectively]. An association was found between sleep bruxism and awake bruxism. It seems that there is a direct or an indirect association between methadone maintenance treatment and sleep bruxism or awake bruxism in male prisoners.

Human compulsivity: A perspective from evolutionary medicine.

Biological explanations address not only proximal mechanisms (for example, the underlying neurobiology of obsessive-compulsive disorder), but also distal mechanisms (that is, a consideration of how particular neurobiological mechanisms evolved). Evolutionary medicine has emphasized a series of explanations for vulnerability to disease, including constraints, mismatch, and tradeoffs. The current paper will consider compulsive symptoms in obsessive-compulsive and related disorders and behavioral addictions from this evolutionary perspective. It will argue that while obsessive-compulsive disorder (OCD) is typically best conceptualized as a dysfunction, it is theoretically and clinically valuable to understand some symptoms of obsessive-compulsive and related disorders in terms of useful defenses. The symptoms of behavioral addictions can also be conceptualized in evolutionary terms (for example, mismatch), which in turn provides a sound foundation for approaching assessment and intervention.

Cultural Impact on SAD: Social Anxiety Disorder among Ethiopian and Former Soviet Union Immigrants to Israel, in Comparison to Native-born Israelis.

BACKGROUND: Social Anxiety Disorder (SAD) is linked to social norms and role expectations which are culture dependent, such as the construal of one's self as independent or interdependent in relation to others. The current study is the first to examine SAD symptoms among Ethiopian and former Soviet Union immigrants to Israel compared to a sample of native Israelis. We investigated the relationship between SAD, ethnicity and independent/ interdependent self-construals. METHODS: A total of 261 students (151 native-born Israelis, 60 Ethiopian immigrants and 50 students from the former USSR) were administrated the Liebowitz Scale (LSAS), the Self-construal Scale (SCS), Beck Depression Inventory (BDI) and a socio-demographic questionnaire. RESULTS: Ethiopians exhibited highest SAD scores while no differences were found between the FSU immigrants and native-born Israelis. Additionally, Ethiopians and native-born Israeli students exhibited similar high interdependence scores. Finally, SAD scores were predicted by gender, origin, independent and interdependent self-construals. CONCLUSION: Immigration per se is not a universal risk factor of SAD and ethnological-cultural factors do contribute specifically to SAD. A possible psychological mediator between culture and the susceptibility to SAD are the interdependence and independent self-construals. When treating immigrants, clinicians and health care providers are advised to consider the effect of cultural influence on the mental well-being and integration process of immigrants in to their host country.

Post-SSRI Sexual Dysfunction: Clinical Characterization and Preliminary Assessment of Contributory Factors and Dose-Response Relationship.

Emerging evidence suggests that sexual dysfunction emerging during treatment with selective serotonin reuptake inhibitors (SSRIs) and/or serotonin-norepinephrine reuptake inhibitors (SNRIs) persists in some patients beyond drug discontinuation (post-SSRI sexual dysfunction [PSSD]). We sought to identify and characterize a series of such cases and explore possible explanatory factors and exposure-response relationship. Subjects who responded to an invitation in a forum dedicated to PSSD filled out a survey via online software. Case probability was defined according to the following 3 categories of increasing presumed likelihood of PSSD. Noncases did not meet the criteria for possible cases. Possible cases were subjects with normal pretreatment sexual function who first experienced sexual disturbances while using a single SSRI/SNRI, which did not resolve upon drug discontinuation for 1 month or longer as indicated by Arizona Sexual Experience Scale scores. High-probability cases were also younger than 50-year-olds; did not have confounding medical conditions, medications, or drug use; and had normal scores on the Hospital Anxiety and Depression Scale. Five hundred thirty-two (532) subjects completed the survey, among which 183 possible cases were identified, including 23 high-probability cases. Female sex, genital anesthesia, and depression predicted current sexual dysfunction severity, but dose/defined daily dose ratio and anxiety did not. Genital anesthesia did not correlate with depression or anxiety, but pleasureless orgasm was an independent predictor of both depression and case probability. Limitations of the study include retrospective design and selection and report biases that do not allow generalization or estimation of incidence. However, our findings add to previous reports and support the existence of PSSD, which may not be fully explained by alternative nonpharmacological factors related to sexual dysfunction, including depression and anxiety.

Seeking proxies for internal states in obsessive-compulsive disorder.

Pervasive doubts are a central feature of obsessive-compulsive disorder (OCD). We have theorized that obsessive doubts can arise in relation to any internal state and lead to compensatory reliance on more discernible substitutes (proxies), including rules and rituals. Previous findings corroborated this hypothesis, but were based on students with high and low OCD tendencies and did not control for anxiety. The present study tested our hypothesis in OCD participants using both anxiety disorders and nonclinical controls. Twenty OCD participants, 20 anxiety disorders participants, and 20 nonclinical participants underwent 2 experimental procedures. In the first, participants had to produce specific levels of muscle tension with and without the aid of biofeedback. In the second, participants were asked to subjectively assess their own muscle tension after viewing preprogrammed false feedback showing either increasing or decreasing levels of muscle tension. As predicted, OCD participants were less accurate than anxiety disorder and nonclinical participants in producing designated levels of muscle tension when biofeedback was not available and more likely to request the biofeedback when given the opportunity to do so. In the false feedback procedure, OCD participants were more influenced by the false biofeedback when judging their own level of muscle tension compared with the 2 controls groups. In both procedures, anxiety disorder participants did not differ from the nonclinical controls. These results support the hypothesis that individuals with OCD have attenuated access to and reduced confidence in their internal states, and that this deficit is specific to OCD and not attributable to anxiety.

Short-term effects of lithium on white blood cell counts and on levels of serum thyroid-stimulating hormone and creatinine in adolescent inpatients: a retrospective naturalistic study.

OBJECTIVE: The purpose of this study was to determine if the known side effects of lithium in adults may be generalized to younger patients with psychiatric disorders. METHODS: A retrospective naturalistic study design was used. Data were collected from the database of a tertiary pediatric medical center covering the years 1994-2010. Included were patients hospitalized for bipolar and non-bipolar disorders and treated with lithium, alone or in combination with other medications. The electronic medical files were reviewed for changes in thyroid and kidney function and for hematological parameters during the course of treatment. RESULTS: Sixty-one patients 12.5-20.4 years of age (mean 16.94±1.66) met the study criteria: 33 with bipolar disorder and 28 with a non-bipolar disorder. Mean duration of lithium treatment (mean lithium blood level, 0.73±0.24 mEq/L) was 193.68±254.35 days. Mean levels of thyroid-stimulating hormones (TSH) rose significantly from baseline to last measurement (3.16±2.68 vs. 1.52±0.92 mU/L; paired t=-5.19, df=50, p<0.001); in 25% of patients, TSH levels at the last measurement were above normal (≥4 mU/L). Only one patient developed TSH values >10 mU/L (the threshold considered clinically significant). Positive correlation was found between pre- and posttreatment TSH levels (Pearson's r=0.60; n=51, p<0.05). White blood cell count (WBC) also increased significantly following lithium treatment (7195±2151 vs. 7944±2096 cells/mm(3); t=2.83, df=60, p=0.006). No significant changes were noted in serum creatinine levels. There was no difference in these parameters between patients treated with lithium alone or in combination with other medications. CONCLUSIONS: Lithium treatment in adolescents with bipolar or non-bipolar disorders is associated with a significant increase in blood TSH levels and WBC count. Lithium-treated adolescent inpatients with a high basal TSH level may be at risk of developing pituitary-thyroid axis dysregulation. Therefore, baseline measurement of thyroid functions and serial monitoring throughout treatment are recommended.

The link between social anxiety disorder, treatment outcome, and sleep difficulties among patients receiving cognitive behavioral group therapy.

OBJECTIVE: The aim of our study was to examine the association between sleep disturbances and social anxiety disorder (SAD). Another aim was to explore the impact of cognitive behavioral group therapy (CBGT) for SAD on co-occurring sleep difficulties. METHODS: Data were obtained retrospectively from patient files receiving CBGT for SAD. The sample included 63 patients with SAD (mean age, 30.42 years [standard deviation, 6.92 years]). There were 41 men and 22 women, of whom 41 participants completed the treatment protocol. Before treatment onset participants completed the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index, and several sociodemographic questions. On completion of the treatment protocol, the same measures were completed, with the addition of the Sheehan Disabilities Scale (SDS). RESULTS: The results of our study suggest that: (1) subjective insomnia is associated with SAD severity even after controlling for depression severity and additional variables; (2) participants with SAD with co-occurring clinical levels of subjective insomnia present a more severe clinical picture both at treatment onset and termination; and (3) although CBGT lead to reduction in SAD and depression symptoms severity, it had no significant impact on co-occurring sleep difficulties. CONCLUSIONS: Sleep difficulties predict SAD severity regardless of depressive symptoms and may be linked to a more severe clinical picture. Clinicians should be aware of these sleep difficulties co-occurring with SAD and consider implementing specific sleep interventions. Future studies should incorporate larger samples sizes from clinical populations outside of Israel.

Impression formation and revision in social anxiety disorder.

Interpersonal relations are markedly impaired in social anxiety. Yet, little is known about the ways social anxiety affects social cognition. We examined impression formation and impression revision among individuals with social anxiety disorder (SAD, n = 26) and non-anxious individuals (n = 29). Participants read initial descriptions of protagonists depicted as dominant, neutral or submissive and rated them on social rank and affiliation dimensions. Next, participants were presented with behavioral acts that were either congruent, incongruent or irrelevant to the initial descriptions, and re-rated the protagonists. Individuals with SAD (a) rated others as more extreme on social rank dimension, (b) rated others as lower on the affiliation dimension, and (c) revised their impressions of others to a greater extent than did the non-anxious individuals. Understanding the ways social anxiety affects the formation and revision of perceptions of others can improve our understanding of maintaining processes in SAD.