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1.
Psychiatry ; 82(3): 198-201, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31566522
2.
J Consult Clin Psychol ; 87(8): 734-744, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31219276

RESUMEN

OBJECTIVE: The therapeutic alliance has long been considered an essential part of treatment. Despite a large body of work examining the alliance-outcome relationship, very few studies have examined it within individuals with first episode psychosis (FEP). METHOD: The present study examined the alliance at Session 3, 4, or 5 and its relationship to 2-year treatment outcomes and therapy participation in a sample of 144 FEP clients who received specialized FEP treatment at U.S. clinics. Furthermore, we examined between-therapist and within-therapist (client) effects of the alliance on outcomes. RESULTS: Results indicated that a better alliance was related to improved mental health recovery, psychological well-being, quality of life, total symptoms, negative symptoms, and disorganized symptoms at the end of treatment. In addition, the between-therapist effect of the alliance was significantly related to better mental health recovery whereas the within-therapist (client) effect of the alliance was related to better quality of life, total symptoms, and negative symptoms at the end of treatment. CONCLUSIONS: A stronger alliance was related to improved treatment outcomes in FEP. Future work should consider examining mediators of the alliance-outcome relationship as well as how changes in the alliance relate to changes in outcomes over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

3.
Schizophr Res ; 2018 Aug 20.
Artículo en Inglés | MEDLINE | ID: mdl-30139553

RESUMEN

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

4.
Schizophr Res ; 2018 Jul 26.
Artículo en Inglés | MEDLINE | ID: mdl-30057099

RESUMEN

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

5.
JAMA Psychiatry ; 75(6): 555-565, 2018 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-29800949

RESUMEN

Importance: The value of early intervention in psychosis and allocation of public resources has long been debated because outcomes in people with schizophrenia spectrum disorders have remained suboptimal. Objective: To compare early intervention services (EIS) with treatment as usual (TAU) for early-phase psychosis. Data Sources: Systematic literature search of PubMed, PsycINFO, EMBASE, and ClinicalTrials.gov without language restrictions through June 6, 2017. Study Selection: Randomized trials comparing EIS vs TAU in first-episode psychosis or early-phase schizophrenia spectrum disorders. Data Extraction and Synthesis: This systematic review was conducted according to PRISMA guidelines. Three independent investigators extracted data for a random-effects meta-analysis and prespecified subgroup and meta-regression analyses. Main Outcomes and Measures: The coprimary outcomes were all-cause treatment discontinuation and at least 1 psychiatric hospitalization during the treatment period. Results: Across 10 randomized clinical trials (mean [SD] trial duration, 16.2 [7.4] months; range, 9-24 months) among 2176 patients (mean [SD] age, 27.5 [4.6] years; 1355 [62.3%] male), EIS was associated with better outcomes than TAU at the end of treatment for all 13 meta-analyzable outcomes. These outcomes included the following: all-cause treatment discontinuation (risk ratio [RR], 0.70; 95% CI, 0.61-0.80; P < .001), at least 1 psychiatric hospitalization (RR, 0.74; 95% CI, 0.61-0.90; P = .003), involvement in school or work (RR, 1.13; 95% CI, 1.03-1.24; P = .01), total symptom severity (standardized mean difference [SMD], -0.32; 95% CI, -0.47 to -0.17; P < .001), positive symptom severity (SMD, -0.22; 95% CI, -0.32 to -0.11; P < .001), and negative symptom severity (SMD, -0.28; 95% CI, -0.42 to -0.14; P < .001). Superiority of EIS regarding all outcomes was evident at 6, 9 to 12, and 18 to 24 months of treatment (except for general symptom severity and depressive symptom severity at 18-24 months). Conclusions and Relevance: In early-phase psychosis, EIS are superior to TAU across all meta-analyzable outcomes. These results support the need for funding and use of EIS in patients with early-phase psychosis.

6.
Schizophr Res ; 194: 4-12, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-28697856

RESUMEN

BACKGROUND: We assessed the prevalence and correlates of lifetime substance use disorders in people with first episode psychosis using the baseline data from the Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program study. METHODS: Research staff assessed 404 first episode patients at 34 community mental health centers across the United States with the Structured Clinical Interview for DSM-IV for diagnoses of psychotic and substance use disorders. Logistic regression was used to evaluate the relationships between participant characteristics and lifetime substance use disorders, followed with generalized linear mixed-effects regression models to identify unique predictors of lifetime substance use disorders. RESULTS: Approximately one-third of participants reported recent alcohol use (36.6%) and cannabis use (30.7%), and one half (51.7%) met criteria for any lifetime alcohol or drug use disorder. Lifetime substance use disorders were associated with male gender, White race, higher excited (hyperactivity, mood lability, impulsivity, hostility, and uncooperativeness), psychotic and depressive symptoms, less impaired cognition, and greater perceived stigma. Gender, race, and excited symptoms were the most consistent unique predictors of lifetime substance use disorders found in multivariate analyses. CONCLUSIONS: Half of first episode psychosis patients have co-occurring substance use disorders, which are associated with both more severe symptoms and greater perceptions of stigma. Programs aiming to serve these patients must have the skills and clinical strategies to help people with these unique characteristics.


Asunto(s)
Trastornos Psicóticos/complicaciones , Trastornos Psicóticos/epidemiología , Esquizofrenia/complicaciones , Esquizofrenia/epidemiología , Trastornos Relacionados con Sustancias/complicaciones , Trastornos Relacionados con Sustancias/epidemiología , Enfermedad Aguda , Comorbilidad , Femenino , Humanos , Entrevista Psicológica , Modelos Logísticos , Masculino , Oportunidad Relativa , Escalas de Valoración Psiquiátrica , Trastornos Psicóticos/psicología , Psicología del Esquizofrénico , Trastornos Relacionados con Sustancias/psicología , Adulto Joven
7.
Schizophr Res ; 193: 64-68, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-28709773

RESUMEN

This study compared baseline characteristics of Black Americans and Caucasians with first-episode psychosis in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP). Black American (N=152) and Caucasian (N=218) participants were compared on demographic, psychosocial, clinical, and neurocognitive measures. Results indicated several notable racial differences in baseline characteristics: a greater proportion of Black Americans than Caucasians were female, and Black Americans reported less personal and parental education than Caucasians. Black Americans were also less likely to have private insurance, more likely to be homeless or transient, had significantly poorer quality of life, more severe disorganized symptoms, worse neurocognition, and were less likely to abuse alcohol than Caucasians. The implications of these findings are discussed, and suggestions are provided for future avenues of treatment and research on racial disparities in first-episode psychosis.


Asunto(s)
Afroamericanos , Trastornos del Conocimiento , Demografía , Esquizofrenia , Psicología del Esquizofrénico , Conducta Social , Adolescente , Adulto , Afroamericanos/psicología , Trastornos del Conocimiento/epidemiología , Trastornos del Conocimiento/etnología , Trastornos del Conocimiento/etiología , Grupo de Ascendencia Continental Europea , Femenino , Humanos , Masculino , Pruebas Neuropsicológicas , Escalas de Valoración Psiquiátrica , Esquizofrenia/complicaciones , Esquizofrenia/epidemiología , Esquizofrenia/etnología , Estados Unidos/epidemiología , Adulto Joven
8.
Schizophr Res ; 195: 448-454, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29033282

RESUMEN

Positive psychology interventions that integrate a person's strengths into treatment result in improvements in life satisfaction and well-being. Character strengths classified within six core virtues (wisdom/knowledge, courage, humanity, justice, temperance, and transcendence) have been the subject of substantial research. Though a number of studies have been conducted in the general population, little is known about the character strengths of individuals with first episode psychosis (FEP). Moreover, positive psychology principles, in particular a focus on personal strengths, have been increasingly integrated into FEP treatment and was a core component of Individual Resiliency Training (IRT), the individual therapy component of NAVIGATE tested in the Recovery After an Initial Schizophrenia Episode Early Treatment Program. As such, the present study offers an examination of character strengths among 105 FEP clients in specialized early intervention treatment. The present study included two primary aims: 1) to conduct a descriptive analysis of character strengths of FEP individuals and 2) to examine exploratory associations between character strengths and changes in symptomatic and recovery variables over six months. Results revealed that the most commonly identified strengths were: Honesty, Authenticity, and Genuineness (40.95%), Kindness and generosity (37.14%), Fairness, equity, and justice (29.52%), Gratitude (29.52%), and Humor and playfulness (29.52%). Three virtues (Humanity, Justice, and Transcendence) were significantly associated with improvements in symptoms, psychological well-being, and interpersonal relations over six months. Overall, the present study offers a glimpse into how persons with FEP view their strengths and how certain clusters of strengths are related to important outcomes.

9.
Am J Psychiatry ; 174(9): 886-894, 2017 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-28427286

RESUMEN

OBJECTIVE: Social Security Administration (SSA) disability benefits are an important source of income for people with psychoses and confer eligibility for health insurance. The authors examined the impact of coordinated specialty care on receipt of such benefits in first-episode psychosis, along with the correlates and consequences of receiving them. METHOD: The Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, a 34-site cluster-randomized trial, compared NAVIGATE, a coordinated specialty care program, to usual community care over 2 years. Receipt of SSA benefits and clinical outcomes were assessed at program entry and every 6 months for 2 years. Piecewise regression analysis was used to identify relative change in outcome trajectories after receipt of disability benefits. RESULTS: Among 399 RAISE-ETP participants, 36 (9%) were receiving SSA disability benefits at baseline; of the remainder, 124 (34.1%) obtained benefits during the 2-year study period. The NAVIGATE intervention improved quality of life, symptoms, and employment but did not significantly reduce the likelihood of receiving SSA disability benefits. Obtaining benefits was predicted by more severe psychotic symptoms and greater dysfunction and was followed by increased total income but fewer days of employment, reduced motivation (e.g., sense of purpose, greater anhedonia), and fewer days of intoxication. CONCLUSIONS: A 2-year coordinated specialty care intervention did not reduce receipt of SSA disability benefits. There were some advantages for those who obtained SSA disability benefits over the 2-year treatment period, but there were also some unintended adverse consequences. Providing income supports without impeding recovery remains an important policy challenge.


Asunto(s)
Renta/estadística & datos numéricos , Seguro por Discapacidad/estadística & datos numéricos , Trastornos Psicóticos/economía , Trastornos Psicóticos/terapia , Adolescente , Adulto , Empleos Subvencionados , Femenino , Humanos , Seguro por Discapacidad/economía , Masculino , Educación del Paciente como Asunto , Medicina de Precisión , Autocuidado , Resultado del Tratamiento , Estados Unidos , United States Social Security Administration/estadística & datos numéricos , Adulto Joven
10.
Schizophr Res ; 185: 167-172, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-27913160

RESUMEN

Recovery-oriented practices that promote client-centered care, collaboration, and functional outcome have been recommended to improve treatment engagement, especially for individuals with serious mental illness (SMI). Psychological well-being (PWB) is related to recovery and refers to experiencing purpose and meaning in life through realizing one's potential. The recently completed Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE ETP) study sought to improve quality of life, functional outcome, and well-being in individuals with first episode psychosis (FEP). Therefore, the primary aims of the present analysis were: 1) to examine the impact of treatment on PWB and mental health recovery trajectories, 2) to examine the impact of duration of untreated psychosis (DUP) on these outcomes, and 3) to examine the relationships among these outcomes and quality of life. Multilevel modeling was used given the nested data structure. Results revealed that PWB and mental health recovery improved over the course of the 2-year treatment; there were no significant treatment differences. In addition, DUP was associated with the Positive Relationships and Environmental Mastery dimensions of PWB. Finally, PWB, mental health recovery, and quality of life were all significantly correlated at baseline while controlling for depressive symptoms. Overall, the findings indicate that PWB and mental health recovery can improve in FEP, are related to yet distinct from quality of life, and that DUP may play a role in certain facets of these constructs.


Asunto(s)
Intervención Precoz (Educación)/métodos , Recuperación de la Salud Mental , Trastornos Psicóticos/psicología , Trastornos Psicóticos/terapia , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Adolescente , Adulto , Factores de Edad , Femenino , Humanos , Masculino , Evaluación de Resultado (Atención de Salud) , Escalas de Valoración Psiquiátrica , Calidad de Vida , Estudios Retrospectivos , Esquizofrenia/terapia , Factores de Tiempo , Adulto Joven
11.
Psychiatry ; 79(3): 206-207, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27880627
12.
Schizophr Bull ; 42(4): 896-906, 2016 07.
Artículo en Inglés | MEDLINE | ID: mdl-26834024

RESUMEN

This study compares the cost-effectiveness of Navigate (NAV), a comprehensive, multidisciplinary, team-based treatment approach for first episode psychosis (FEP) and usual Community Care (CC) in a cluster randomization trial. Patients at 34 community treatment clinics were randomly assigned to either NAV (N = 223) or CC (N = 181) for 2 years. Effectiveness was measured as a one standard deviation change on the Quality of Life Scale (QLS-SD). Incremental cost effectiveness ratios were evaluated with bootstrap distributions. The Net Health Benefits Approach was used to evaluate the probability that the value of NAV benefits exceeded its costs relative to CC from the perspective of the health care system. The NAV group improved significantly more on the QLS and had higher outpatient mental health and antipsychotic medication costs. The incremental cost-effectiveness ratio was $12 081/QLS-SD, with a .94 probability that NAV was more cost-effective than CC at $40 000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.


Asunto(s)
Servicios Comunitarios de Salud Mental/normas , Análisis Costo-Beneficio , Prestación Integrada de Atención de Salud/normas , Evaluación de Resultado (Atención de Salud) , Grupo de Atención al Paciente/normas , Trastornos Psicóticos/terapia , Esquizofrenia/terapia , Adolescente , Adulto , Servicios Comunitarios de Salud Mental/economía , Prestación Integrada de Atención de Salud/economía , Femenino , Investigación sobre Servicios de Salud , Humanos , Masculino , National Institute of Mental Health (U.S.) , Grupo de Atención al Paciente/economía , Trastornos Psicóticos/economía , Esquizofrenia/economía , Estados Unidos , Adulto Joven
13.
Acad Med ; 91(5): 730-42, 2016 05.
Artículo en Inglés | MEDLINE | ID: mdl-26796091

RESUMEN

PURPOSE: Behavioral and social science (BSS) competencies are needed to provide quality health care, but psychometrically validated measures to assess these competencies are difficult to find. Moreover, they have not been mapped to existing frameworks, like those from the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). This systematic review aimed to identify and evaluate the quality of assessment tools used to measure BSS competencies. METHOD: The authors searched the literature published between January 2002 and March 2014 for articles reporting psychometric or other validity/reliability testing, using OVID, CINAHL, PubMed, ERIC, Research and Development Resource Base, SOCIOFILE, and PsycINFO. They reviewed 5,104 potentially relevant titles and abstracts. To guide their review, they mapped BSS competencies to existing LCME and ACGME frameworks. The final included articles fell into three categories: instrument development, which were of the highest quality; educational research, which were of the second highest quality; and curriculum evaluation, which were of lower quality. RESULTS: Of the 114 included articles, 33 (29%) yielded strong evidence supporting tools to assess communication skills, cultural competence, empathy/compassion, behavioral health counseling, professionalism, and teamwork. Sixty-two (54%) articles yielded moderate evidence and 19 (17%) weak evidence. Articles mapped to all LCME standards and ACGME core competencies; the most common was communication skills. CONCLUSIONS: These findings serve as a valuable resource for medical educators and researchers. More rigorous measurement validation and testing and more robust study designs are needed to understand how educational strategies contribute to BSS competency development.


Asunto(s)
Ciencias de la Conducta/educación , Educación de Postgrado en Medicina/normas , Educación de Pregrado en Medicina/normas , Evaluación Educacional/métodos , Ciencias Sociales/educación , Competencia Clínica/normas , Evaluación Educacional/normas , Humanos , Psicometría , Reproducibilidad de los Resultados , Estados Unidos
14.
Am J Psychiatry ; 173(4): 362-72, 2016 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-26481174

RESUMEN

OBJECTIVE: The primary aim of this study was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis designed for implementation in the U.S. health care system, with community care on quality of life. METHOD: Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or community care. Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age, 23) with schizophrenia and related disorders and ≤6 months of antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning, and engagement in regular activities. RESULTS: The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks. NAVIGATE participants with duration of untreated psychosis of <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in community care. Rates of hospitalization were relatively low compared with other first-episode psychosis clinical trials and did not differ between groups. CONCLUSIONS: Comprehensive care for first-episode psychosis can be implemented in U.S. community clinics and improves functional and clinical outcomes. Effects are more pronounced for those with shorter duration of untreated psychosis.


Asunto(s)
Antipsicóticos/uso terapéutico , Servicios Comunitarios de Salud Mental/métodos , Educación Especial , Empleos Subvencionados , Educación del Paciente como Asunto , Psicoterapia , Trastornos Psicóticos/terapia , Esquizofrenia/terapia , Adolescente , Adulto , Familia , Femenino , Humanos , Masculino , National Institute of Mental Health (U.S.) , Grupo de Atención al Paciente , Calidad de Vida , Factores de Tiempo , Estados Unidos , Adulto Joven
15.
Psychol Men Masc ; 16(3): 274-283, 2015 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-26366126

RESUMEN

Researchers have called for qualitative investigations into African American fathers' parenting practices that consider their social context and identify specific practices. Such investigations can inform the way we conceptualize African American fathers' parenting practices, which can in turn contribute to prevention interventions with at-risk youth. We conducted semi-structured, qualitative interviews about parenting with 30 self-identified, African American, biological fathers of pre-adolescent sons at-risk for developing aggressive behaviors, depressive symptoms, or both. Fathers provided descriptions of their parenting practices, which were at times influenced by their environmental context, fathers' residential status, and masculine ideologies. Our systematic analysis revealed four related themes that emerged from the data: managing emotions, encouragement, discipline, and monitoring. Of particular note, fathers in the current sample emphasized the importance of teaching their sons to manage difficult emotions, largely utilized language consistent with male ideologies (i.e., encouragement rather than love or nurturance), and engaged in high levels of monitoring and discipline in response to perceived environmental challenges and the developmental needs of their sons. The findings provide deeper insight into the parenting practices of African American fathers who are largely understudied, and often misunderstood. Further, these findings highlight considerations that may have important implications for father-focused prevention interventions that support African American fathers, youth, and families.

16.
J Clin Psychiatry ; 76(3): 240-6, 2015 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-25830446

RESUMEN

OBJECTIVE: The premise of the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) is to combine state-of-the-art pharmacologic and psychosocial treatments delivered by a well-trained, multidisciplinary team in order to significantly improve the functional outcome and quality of life for first-episode psychosis patients. The study is being conducted in non-academic (ie, real-world) treatment settings, using primarily extant reimbursement mechanisms. METHOD: We developed a treatment model and training program based on extensive literature review and expert consultation. Our primary aim is to compare the experimental intervention to "usual care" on quality of life. Secondary aims include comparisons on remission, recovery, and cost-effectiveness. Patients 15-40 years old with a first episode of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder not otherwise specified, or brief psychotic disorder according to DSM-IV and no more than 6 months of treatment with antipsychotic medications were eligible. Patients are followed for a minimum of 2 years, with major assessments conducted by blinded, centralized raters using live, 2-way video. We selected 34 clinical sites in 21 states and utilized cluster randomization to assign 17 sites to the experimental treatment and 17 to usual care. Enrollment began in July 2010 and ended in July 2012 with 404 subjects. The results of the trial will be published separately. The goal of the article is to present both the overall development of the intervention and the design of the clinical trial to evaluate its effectiveness. CONCLUSIONS: We believe that we have succeeded in both designing a multimodal treatment intervention that can be delivered in real-world clinical settings and implementing a controlled clinical trial that can provide the necessary outcome data to determine its impact on the trajectory of early phase schizophrenia. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01321177.


Asunto(s)
Intervención Médica Temprana/normas , Trastornos Psicóticos/terapia , Proyectos de Investigación/normas , Esquizofrenia/terapia , Adolescente , Adulto , Terapia Combinada/normas , Humanos , Evaluación de Resultado (Atención de Salud) , Trastornos Psicóticos/tratamiento farmacológico , Esquizofrenia/tratamiento farmacológico , Adulto Joven
17.
Am J Psychiatry ; 172(3): 237-48, 2015 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-25727536

RESUMEN

OBJECTIVE: Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients. METHOD: Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project's Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry. RESULTS: The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine (often at high dosages), 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects. CONCLUSIONS: Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.


Asunto(s)
Antidepresivos/uso terapéutico , Antipsicóticos/uso terapéutico , Prestación de Atención de Salud , Pautas de la Práctica en Medicina/estadística & datos numéricos , Esquizofrenia , Adulto , Prestación de Atención de Salud/métodos , Prestación de Atención de Salud/normas , Episodio de Atención , Femenino , Humanos , Seguro , Masculino , Administración del Tratamiento Farmacológico , Evaluación de Necesidades , Escalas de Valoración Psiquiátrica , Características de la Residencia , Esquizofrenia/diagnóstico , Esquizofrenia/tratamiento farmacológico , Esquizofrenia/economía , Factores Socioeconómicos
18.
JAMA Psychiatry ; 71(12): 1350-63, 2014 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-25321337

RESUMEN

IMPORTANCE: The fact that individuals with schizophrenia have high cardiovascular morbidity and mortality is well established. However, risk status and moderators or mediators in the earliest stages of illness are less clear. OBJECTIVE: To assess cardiometabolic risk in first-episode schizophrenia spectrum disorders (FES) and its relationship to illness duration, antipsychotic treatment duration and type, sex, and race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS: Baseline results of the Recovery After an Initial Schizophrenia Episode (RAISE) study, collected between July 22, 2010, and July 5, 2012, from 34 community mental health facilities without major research, teaching, or clinical FES programs. Patients were aged 15 to 40 years, had research-confirmed diagnoses of FES, and had less than 6 months of lifetime antipsychotic treatment. EXPOSURE: Prebaseline antipsychotic treatment was based on the community clinician's and/or patient's decision. MAIN OUTCOMES AND MEASURES: Body composition and fasting lipid, glucose, and insulin parameters. RESULTS: In 394 of 404 patients with cardiometabolic data (mean [SD] age, 23.6 [5.0] years; mean [SD] lifetime antipsychotic treatment, 47.3 [46.1] days), 48.3% were obese or overweight, 50.8% smoked, 56.5% had dyslipidemia, 39.9% had prehypertension, 10.0% had hypertension, and 13.2% had metabolic syndrome. Prediabetes (glucose based, 4.0%; hemoglobin A1c based, 15.4%) and diabetes (glucose based, 3.0%; hemoglobin A1c based, 2.9%) were less frequent. Total psychiatric illness duration correlated significantly with higher body mass index, fat mass, fat percentage, and waist circumference (all P<.01) but not elevated metabolic parameters (except triglycerides to HDL-C ratio [P=.04]). Conversely, antipsychotic treatment duration correlated significantly with higher non-HDL-C, triglycerides, and triglycerides to HDL-C ratio and lower HDL-C and systolic blood pressure (all P≤.01). In multivariable analyses, olanzapine was significantly associated with higher triglycerides, insulin, and insulin resistance, whereas quetiapine fumarate was associated with significantly higher triglycerides to HDL-C ratio (all P≤.02). CONCLUSIONS AND RELEVANCE: In patients with FES, cardiometabolic risk factors and abnormalities are present early in the illness and likely related to the underlying illness, unhealthy lifestyle, and antipsychotic medications, which interact with each other. Prevention of and early interventions for psychiatric illness and treatment with lower-risk agents, routine antipsychotic adverse effect monitoring, and smoking cessation interventions are needed from the earliest illness phases.


Asunto(s)
Antipsicóticos/efectos adversos , Enfermedades Cardiovasculares/metabolismo , Síndrome Metabólico/metabolismo , Trastornos Psicóticos/metabolismo , Esquizofrenia/metabolismo , Adolescente , Adulto , Glucemia/metabolismo , Composición Corporal , Enfermedades Cardiovasculares/inducido químicamente , Enfermedades Cardiovasculares/complicaciones , Grupos Étnicos , Femenino , Humanos , Insulina/sangre , Lípidos/sangre , Masculino , Síndrome Metabólico/sangre , Síndrome Metabólico/inducido químicamente , Síndrome Metabólico/complicaciones , Persona de Mediana Edad , Obesidad/complicaciones , Sobrepeso/complicaciones , Estudios Prospectivos , Trastornos Psicóticos/sangre , Trastornos Psicóticos/complicaciones , Factores de Riesgo , Esquizofrenia/sangre , Esquizofrenia/complicaciones , Esquizofrenia/tratamiento farmacológico , Factores Sexuales , Factores de Tiempo , Adulto Joven
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