Perceptions of schizophrenia and coping styles in caregivers: comparison between India and Switzerland.

WHAT IS KNOWN ON THE SUBJECT?: Negative perceptions of illnesses can increase caregivers' use of ineffective coping strategies, which may increase their burdens and distress. Scientific and theoretical framework showed that culture and health organization system influence perception of illnesses and thus also has an impact on the coping strategies used. There is a lack of data on comparative perceptions of illnesses and coping styles between India and Switzerland and that is why this hypothesis needs to be confirmed. The comparison between two countries with large cultural and socioeconomics differences will provide a more significant impact. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This cultural comparative study explores the associations between representations of illness and three forms of coping styles (i.e. problem-focused, emotion-focused and social support-focused coping) among caregivers of people diagnosed with schizophrenia spectrum disorders in Mangalore, India, and in French-speaking Switzerland. Results showed significant differences between Swiss and Indian caregivers practically in all illness' perceptions and coping styles, which is in accord with the theoretical framework. However, two results showed also similarities: the perception that schizophrenia can have cyclical episodes and that it can have negative consequences for caregivers. These differences and similarities allow to confirm the hypothesis that culture and health organization system influence illness' perception which impact the used coping styles. However, to develop specific nursing interventions for each culture, more research is needed to specify qualitatively the content of these differences and similarities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Knowledge of how culture influences perceptions and coping styles is essential to develop quality interventions. Nurses should evaluate caregivers' perceptions and the causes they attribute to illnesses to help them maintain or develop efficient coping strategies. Knowledge of specific cultural differences and similarities can help nurses to provide individualized care that takes into account personal values to ensure recovery processes. ABSTRACT: Introduction Scientific and theoretical framework showed that culture and health organization system influence perception of illnesses and thus also has an impact on the coping strategies used. Aim/question This cultural comparative study explores illness' perception and coping styles among the caregivers of people diagnosed with schizophrenia spectrum disorders in Mangalore, India, and Lausanne, Switzerland. Method The answers of 92 Swiss caregivers, using paper or electronic surveys depending on the participants' preference, and 100 Indian caregivers via an interview with a nurse were examined. Results The results confirm the hypothesis that culture and health organization system influence illness' perception which impact the used coping styles. Significant differences between Swiss and Indian caregivers practically in all illness' perceptions and coping styles were present, which is in accord with the theoretical framework. However, two results showed also similarities: the perception that schizophrenia can have cyclical episodes and that it can have negative consequences for caregivers. Discussion These differences will affect the development of interventions for caregivers in both countries. Implications for Practice The cultural differences observed in this study not only will allow interventions to be adapted to the specific needs of the two populations but also to identify their shared needs.

Sustained antipsychotic effect of metacognitive training in psychosis: a randomized-controlled study.

Persistent psychotic symptoms represent a major challenge for psychiatric care. Basic research has shown that psychotic symptoms are associated with cognitive biases. Metacognitive training (MCT) aims at helping patients to become aware of these biases and to improve problem-solving. Fifty-two participants fulfilling diagnostic criteria of schizophrenia or schizoaffective disorders and persistent delusions and stabilized antipsychotic medication were enrolled in this study. Following baseline assessment patients were randomized either to treatment as usual (TAU) conditions or TAU+MCT. The intervention consisted of eight weekly 1-hour sessions (maximum: 8 hours). Participants were assessed at 8 weeks and 6-months later by blind assessors. Participants were assessed with the Psychotic Symptoms Rating Scales (PSYRATS) and the positive subscale of the PANSS. Between-group differences in post- and pre-test values were significant at a medium effect size in favor of the MCT for the PSYRATS delusion scale and the positive scale of the PANSS both at post and follow-up. The results of this study indicate that MCT training has a surplus antipsychotic effect for patients suffering from schizophrenia-related disorders who demonstrate only a partial response to antipsychotic treatment and that the effect of the intervention persists for at least 6 months after the intervention.

[French translation, validation and adaptation of the Stigma Scale]. / Mesurer la stigmatisation perçue chez les personnes souffrant de troubles psychiques: traduction française, validation et adaptation de la Stigma Scale.

AIM: People suffering from mental illness are exposed to stigma. However, only few tools are available to assess stigmatization as perceived from the patient's perspective. The aim of this study is to adapt and validate a French version of the Stigma Scale (King et al., 2007 [8]). This self-report questionnaire has a three-factor structure: discrimination, disclosure and positive aspects of mental illness. Discrimination subscale refers to perceived negative reactions of others. Disclosure subscale refers mainly to managing disclosure to avoid discrimination and finally positive aspects subscale taps into how patients are becoming more accepting, more understanding toward their illness. METHOD: In the first step, internal consistency, convergent validity and test-retest reliability of the French adaptation of the 28-item scale were assessed in a sample of 183 patients. Results of confirmatory factor analyses (CFA) did not confirm the hypothesized structure. In the light of the failed attempts to validate the original version, an alternative 9-item short-form version of the Stigma Scale, maintaining the integrity of the original model, was developed based on results of exploratory factor analyses in the first sample and cross-validated in a new sample of 234 patients. RESULTS: Results of CFA did not confirm that the data fitted well to the three-factor model of the 28-item Stigma Scale (χ(2)/df=2.02, GFI=0.77, AGFI=0.73, RMSEA=0.07, CFI=0.77 and NNFI=0.75). Cronbach's α was excellent for discrimination (0.84) and disclosure (0.83) subscales but poor for potential positive aspects (0.46). External validity was satisfactory. Overall Stigma Scale total score was negatively correlated with the score on Rosenberg's Self-Esteem Scale (r=-0.49), and each subscale was significantly correlated with a visual analogue scale that referred to the specific aspect of stigma (0.43≤|r|≤0.60). Intraclass correlation coefficients between 0.68 and 0.89 indicated good test-retest reliability. The results of the CFA demonstrated that the items chosen for the short version of the Stigma Scale have the expected fit properties (χ(2)/df=1.02, GFI=0.98, AGFI=0.98, RMSEA=0.01, CFI=1.0 and NNFI=1.0). Considering the small number (three) of items in each subscale of the short version of the Stigma Scale, α coefficients for discrimination (0.57), disclosure (0.80) and potential positive aspects subscales (0.62) are considered as good. CONCLUSION: Our results suggest that the 9-item French short version of the Stigma Scale is a useful, reliable and valid self-report questionnaire to assess perceived stigmatization in people suffering from mental illness. The time of completion is really short and questions are well understood and accepted by the patients.

[Stigma of "madness" from fate to recovery]. / Le stigmate de la "folie": de la fatalité au rétablissement.

Stigma is a "natural" social reaction, partly unconscious and automatic towards "different" and "vulnerable" populations. Suspicion of danger, unemployment, excluded from society, locked in hospital, assaulted or killed are the possible consequences of mental disorders' stigma. Despite advances in psychiatric treatments, the stigma of the "madness" remains a barrier to access to recovery. The stigmatization process is more complex than simple labeling, and leads to discrimination and loss of social power. Understanding the mechanisms of stigmatization can determine targets for effective interventions to fight stigma at the individual, institutional and political levels. The roles of patient and family associations, as well as the recovery model for the professionals, are essential. The aim of this article is to review the various aspects of mental disorders' stigma and to examine ways to cope with them.

[Validation of the Temporal Experience of Pleasure Scale (TEPS) in a French-speaking environment]. / Validation française de l'échelle d'expérience temporelle du plaisir.

INTRODUCTION: Anhedonia is defined as a diminished capacity to experience pleasant emotion and is commonly included among the negative symptoms of schizophrenia. However, if patients report experiencing a lower level of pleasure than controls, they report experiencing as much pleasure as controls with online measurements of emotion. OBJECTIVE: The Temporal Experience of Pleasure Scale (TEPS) measures pleasure experienced in the moment and in anticipation of future activities. The TEPS is an 18-item self-report measurement of anticipatory (10 items) and consummatory (eight items) pleasure. The goal of this paper is to assess the psychometric characteristics of the French translation of this scale. METHODS: A control sample was composed of 60 women and 22 men, with a mean age of 38.1 years (S.D.: 10.8). Thirty-six were without qualification and 46 with qualified professional diploma. A sample of 21 patients meeting DSM IV-TR criteria for schizophrenia was recruited among the community psychiatry service of the department of psychiatry in Lausanne. They were five women and 16 men; mean age was of 34.1 years (S.D.: 7.5). Ten obtained a professional qualification and 11 were without qualification. None worked in competitive employment. Their mean dose of chlorpromazine equivalent was 431 mg (S.D.: 259). All patients were on atypical antipsychotics. The control sample fulfilled the TEPS and the Physical Anhedonia Scale (PAS). The patient sample fulfilled the TEPS and was independently rated on the Calgary Depression Scale and the Scale for Assessment of Negative Symptoms. For comparison with controls, patients were matched on age, sex and professional qualification. This required the supplementary recruitment of two control subjects. RESULTS: Results with the control sample indicate that the TEPS presents an acceptable internal validity with Crombach alphas of 0.84 for the total scale, 0.74 for the anticipatory pleasure scale and 0.79 for the consummatory pleasure scale. The confirmatory factor analysis indicated that the model is well adapted to our data (chi(2)/dl=1.333; df=134; p<0.0006; root mean square residual, RMSEA=0.064). External validity measured with the PAS showed R=-0.27 (p<0.05) for the consummatory scale and R=-0.26 for the total score. Comparisons between patients and matched controls indicated that patients were significantly lower than control on anticipatory pleasure (t=2.7, df(40), 2-tailed p=0.01; cohen's d=0.83) and on total score of the TEPS (t=2.8, df (40), 2-tailed p=0.01; cohen's d=0.87). The two samples did not differ on consummatory pleasure. The anticipatory pleasure factor and the total TEPS showed significant negative correlation with the SANS anhedonia, respectively R=-0.78 (p<0.01) for the anticipatory factor and R=-0.61 (p<0.01) for the total TEPS. There was also a negative correlation between the anticipatory factor and the SANS avolition of R=-0.50 (p<0.05). These correlations were maintained, with partial correlations controlling for depression and chlorpromazine equivalents. CONCLUSION: The results of this validation show that the French version of the TEPS has psychometric characteristics similar to the original version. These results highlight the discrepancy between results of direct or indirect report of experienced pleasure in patients with schizophrenia. Patients may have difficulties in anticipating the pleasure of future enjoyable activities, but not in experiencing pleasure once in an enjoyable activity. Medication and depression do not seems to modify our results, but this should be better controlled in a longitudinal study. The anticipatory versus consummatory pleasure distinction appears to be useful for the development of new psychosocial interventions, tailored to improve desire in patients suffering from schizophrenia. Major limitations of the study are the small size of patient sample and the under representation of men in the control sample.

[Motivational interventions: psychosis and cannabis]. / Interventions motivationnelles: psychose et cannabis.

Cannabis use by people suffering from schizophrenia increase relapse rate and reduce adhesion to treatment. Motivational interventions could reduce cannabis misuse. The motivational interviewing principles and techniques are presented in a concrete way as well as the required adaptations to bypass cognitive deficits associated with schizophrenia.

[Mental retardation and psychiatry]. / Handicap mental et psychiatrie.

In the canton de Vaud (Switzerland) the psychiatric units devoted to mental retardation have been suppressed during the deinstitutionalization process in the 1970/80s. However, the use of psychiatric hospitalizations has increased these last years. This increase is accompanied by an interdiction of seclusion and restraint outside of the specialized psychiatric unit. A unit of liaison psychiatry has been created as an alternative to psychiatric hospitalization and to assist directly the staff of specialized institutions for people with mental retardation or the family of the patient. The article describes the challenges of liaison psychiatry in this field and the potential benefits of research for the psychiatry of mental retardation.

[Motivational interviewing for cannabis users with psychotic disorders]. / Une intervention motivationnelle pour les consommateurs de cannabis souffrant de psychose.

BACKGROUND: People suffering from psychiatric disorders abuse alcohol or illicit substances twice as frequently as the general population. This problem is even more frequent in the early phase of psychotic disorders where prevalence of substance abuse ranges, according to various studies, from 35 to 65% during first psychotic episode. Cannabis is currently the most frequently used substance, and although its impact is often minimised, many data suggest it constitutes a risk for psychosis at three levels: (a) possible toxic psychosis in healthy individuals, (b) relapse of positive symptoms in schizophrenia and (c) raises the risk of schizophrenia when used early during adolescence. Despite a persistent controversy regarding some of these findings, they have constituted a sufficient body of evidence to support the development of specific interventions for psychotic patients. Various authors have described the fundamental elements of such dual diagnosis treatments, and some intervention programs have recently been developed. However, their relative complexity and the long duration of such interventions are often not well adapted to patients with limited motivation and low level of insight. Moreover, many obstacles arise that complicate their application to early psychotic disorders: minimisation of deleterious effect of cannabis by young people, distrust linked to psychotic symptoms, cognitive disturbances, stigmatisation of psychiatry, and use of cannabis as a means to socialise with peers. It is therefore important to adapt interventions to the specific needs of such patients and particularly to adopt a realistic attitude, aiming at increasing motivation to change habits and minimising associated risks rather than total abstinence. Our objective is to develop a pragmatic, non-judgemental approach, based on motivational interviewing techniques that is adapted to early psychosis with comorbid cannabis abuse, aimed at reducing the risks associated with abuse. In this article, we describe the basic principles and various stages of a brief motivational intervention developed for the treatment of cannabis abusers, going through the early phase of a psychotic disorder. The conceptualisation of the intervention was based on an extensive literature review and our experience in the treatment of such patients, as well as in the treatment of alcohol abuse through motivational interview. METHODS: Our intervention uses motivational interviewing techniques (empathic, non-judgemental approach, aimed at developing insight regarding potential consequences of cannabis abuse through the exploration of both its positive and negative aspects) and can be adapted to the patient's stage of motivation for change. Its basic principles are: (a) to address questions related to psychosis and cannabis simultaneously; (b) to take into account cognitive dysfunction related to illness and treatment; (c) to adapt techniques of reflective listening; and (d) to structure the interview through frequent summaries and by considering successively the positive and negative aspects of cannabis. The intervention is composed of four sessions: (1) creation of an alliance and evaluation of the level of cannabis abuse; (2) development of motivation to change by increasing contradictions between patient's affirmations; (3) definition of objectives according to the level of motivation to change; and (4) adaptation of the subsequent intervention according to the degree of motivation to change. RESULTS: A pilot study showed that this intervention can be implemented in the target population. It revealed that it facilitated the establishment of a trustful relationship, in the frame of which ambivalence regarding cannabis abuse could be explored. The fact that the therapist makes the first step, shows empathy and tries to understand patient's motivations to use cannabis, leads patients to expose their ambivalence with less reluctance and to become more aware of the possible links between cannabis and psychotic disorders. CONCLUSION: This method is particularly well adapted to patients who are in a precontemplative stage. Additional studies are needed in order to evaluate its efficacy in terms of decrease in the risks related to cannabis abuse.

The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis.

BACKGROUND: Despite the effectiveness of anti-psychotic pharmacotherapy, residual hallucinations and delusions do not completely resolve in some medicated patients. Additional cognitive behavioral therapy (CBT) seems to improve the management of positive symptoms. Despite promising results, the efficacy of CBT is still unclear. The present study addresses this issue taking into account a number of newly published controlled studies. METHOD: Fourteen studies including 1484 patients, published between 1990 and 2004 were identified and a meta-analysis of their results performed. RESULTS: Compared to other adjunctive measures, CBT showed significant reduction in positive symptoms and there was a higher benefit of CBT for patients suffering an acute psychotic episode versus the chronic condition (effect size of 0.57 vs. 0.27). DISCUSSION: CBT is a promising adjunctive treatment for positive symptoms in schizophrenia spectrum disorders. However, a number of potentially modifying variables have not yet been examined, such as therapeutic alliance and neuropsychological deficits.

Benevolent voices are not so kind: the functional significance of auditory hallucinations.

BACKGROUND: This study measures the impact of beliefs about auditory hallucinations on social functioning. SAMPLING AND METHODS: Twenty-nine subjects who met the ICD-10 criteria for schizophrenia or a schizo-affective disorder were included. Beliefs about voices and coping responses as measured by the Beliefs about Voices Questionnaire were compared with social functioning as assessed with the Life Skills Profile (LSP). RESULTS: The belief that voices are benevolent was associated with poor communication. Engagement with voices was correlated with the non-turbulence and the compliance factors of the LSP. Patients who held the belief that their voices were benevolent functioned significantly more poorly on the communication factor of the LSP than patients who interpreted their voices as malevolent. DISCUSSION: The results indicate that a positive relationship with voices may affect social functioning. However, the size of the sample is small and patients with benevolent voices are overrepresented. Nonetheless, these results have implications for the use of cognitive therapy for psychotic symptoms.

[Validation of the French Version of the Life Skills Profile with people suffering of schizophrenia]. / Validation de la version française du Profil des compétences de vie (Life Skills Profile) chez des personnes atteintes de schizophrénie.

INTRODUCTION: Since the discovery of neuroleptics and the reintegration of people with schizophrenia in the community, psycho-social reeducation became an essential part of the treatment. The Life Skills Profile is a tool of reference for assessment of the dimensions, which have an impact on the adaptation in community. Each item describes an observable behavior, written in common language, to allow the care-givers and the family to evaluate it without having a specific formation. The long version (39 items) is recommended for therapeutic interventions with a person and the short one (20 items) for large scale studies on outcome in community. AIM OF THE STUDY: In order to dispose of a measure of function and disability in schizophrenia, we have translated the Life Skills Profile (LSP) in French and tested the validity of this translation for the long version (39 items) and the short ones (16 and 20 items). The 4 dimensions of the 16-items version--"withdrawal", "self-care", "compliance" and "antisocial"--were used for people with mental disorders and the 20-items version enhanced with a fifth dimension "bizarre", especially useful for people with schizophrenia. METHOD: 175 people suffering of schizophrenia (DSM IV, codes F20.0 to F20.5) were evaluated by their caregivers in 3 settings: psychiatric hospital, ambulatory care and sheltered homes. Confirmatory factorial analyses were performed to test the dimensional models and their psychometric characteristics were established. RESULTS: The original structure in 5 dimensions of the long version (39 items) is not confirmed. However, the short versions in 16 and 20 items were confirmed, without any modification. The required psychometric qualities of reliability and validity of the 20-items version were fulfilled. The inter-rater reliability ranged from 0.65 to 0.75 for the 5 dimensions; the test-retest reliability ranged from 0.80 to 0.91 and the internal consistency from 0.67 to 0.81. The validity was evaluated by comparison of the LSP scores upon living arrangements (people living in sheltered homes had lesser scores) and pathologies (19 people with severe major depression had higher scores). CONCLUSION: The 39-items version of the Life Skills Profile was not validated in French. However, for clinical practice of social rehabilitation, this tool remains useful for a single person to check specific behaviors, which could hinder his/her integration into the community, to plan specific interventions and to evaluate changes, in addition with other scales. By the validation of the short version of the Life Skills Profile, an instrument is at disposal in French for outcome studies which allow to: 1) quickly assess the social functioning of person suffering of schizophrenia by a caregiver or a family member; 2) to detect insufficient skills in specific domains; and 3) to evaluate therapeutic efficiency.

[Effect of a coordinated management program on the outcome of a cohort of ambulatory psychiatric patients]. / Etude de l'effet d'un programme de soins coordonnés sur l'évolution d'une cohorte de patients psychiatriques ambulatoires.

This study describes a one year follow-up study of 53 ambulatory patients treated with case management oriented care. These patients, characterized by a chronic evolution for an average of 10 years, presented after a one year period a significant improvement of different symptomatic parameters (positive and negative psychotic symptoms). Psychosocial adaptation was also improved for their dependency, their activity and the amount of their social contacts. These results underline the usefulness of case management, which permits an optimal use of available therapeutic facilities. Moreover, the setting of such a program allows a more specifical treatment of this category of patients.

[Patient education about neuroleptic treatment, can it reduce costs? A pilot study]. / L'éducation au traitement neuroleptique peut-elle réduire les coûts? Une évaluation pilote.

Costs generated by chronically mentally ill are very high. Concerning direct costs (hospitalisations, outpatient services, medications), they are estimated from 120,000 to 160,000 french francs per year. Indirect costs (social security, gain lost) are assessed as being at least three times more than direct costs. Trimestrial costs, charged to insurance, of the first fourteen patients who followed the UCLA medication management module, have been retrospectively calculated on the base of the number of consultations, days at the hospital and community day center during the previous and following year of the introduction of the program. The intervention lasts 3 months with two weekly sessions of 1 h 30. The medication module aims the following goals: 1) Obtaining information about antipsychotic medication; 2) Knowing correct self-administration and evaluation of medication; 3) Identifying side effects of medication; and 4) Negotiating medication issues with health-care providers. The mean trimestrial costs curve goes down following the application of the program and this reduction continues 9 months after the end of the intervention. The small numbers of patients and the absence of control group do not allow to draw conclusions about these results. However, these data provide support to formulate an hypothesis about the effect of the module on medication compliance.