Listening to Cancer Patients' Narratives During Residency: A Pilot Study on a Communication Skills' Workshop Involving Patients-Partners.

The field of cancer care still lacks best practices in communication. Few postgraduate training programs offer formal training to develop such skills. The patient partnership has been used in medical education to increase the sensitivity of the subjective experiences of patients. In our Canadian center, residents and patient-partners participated in an educational workshop on communication focusing on patient's narrative. The aim of this pilot qualitative study was to explore the experiences of participants in the workshop. Using theoretical sampling, we recruited 6 residents and 6 patient-partners. Semi-structured interviews were conducted and transcribed. A thematic analysis was performed. From analysis, 4 themes emerged: (1) lack of communication skills training; (2) barriers to effective communication in cancer care; (3) the empathy of patient-partners towards the communication challenges faced by residents; and (4) the participants' reactions to the workshop. Based on our findings, our communication skills workshop centered on narrative medicine and involving patient-partners appears feasible. Future research could study its pedagogical value and the optimal learning environment required.

Explicit and Implicit Attitudes of Canadian Psychiatrists Toward People With Mental Illness.

OBJECTIVE: People with mental illness suffer stigma and discrimination across various contexts, including the health care setting, and clinicians' attitudes play an important role in perpetuating stigma. Effective stigma-reduction interventions for physicians require a better understanding of explicit (that is, conscious and controllable) and implicit (that is, subconscious and automatic) forms of bias, and of predictors and moderators of stigma. METHODS: Members of a Canadian university psychiatry department and of the Canadian Psychiatric Association (CPA) were invited to participate in a web-based study consisting of 2 measures of explicit attitudes, the Social Distance Scale (SDS) and the Opening Minds Scale for Health Care Providers (OMS-HC), and 1 measure of implicit attitudes, the Implicit Association Test (IAT). RESULTS: Thirty-five psychiatry residents and 68 psychiatrists completed the study (response rates of 12.1% for the university sample and 3.3% for the CPA sample). Participants desired greater social distance from the vignette patient with schizophrenia. Mean IAT scores, although negative, did not reach the threshold for a meaningful effect size. Patient contact positively predicted IAT scores, while age, sex, and level of training (resident, compared with psychiatrist) did not. Neither patient contact nor implicit attitudes predicted SDS or OMS-HC scores. CONCLUSION: Psychiatrists did not differ from psychiatry residents on any measures of explicit or implicit attitudes toward mental illness. Explicit attitudes toward people with mental illness were relatively negative; implicit attitudes were neither negative nor positive; and implicit and explicit attitudes were not correlated. Greater patient contact predicted more positive implicit attitudes, but did not predict explicit attitudes.

A randomized controlled trial with a Canadian electronic pill dispenser used to measure and improve medication adherence in patients with schizophrenia.

OBJECTIVE: Medication adherence is extremely important in preventing relapse and lowering symptoms in schizophrenic patients. However, estimates show that nearly half of these patients have poor adherence. The Brief Adherence Rating Scale (BARS) seems to be the most reliable tool assessing adherence in schizophrenia and shows that the antipsychotic adherence ratio (AAR) is about 49.5% in schizophrenia. The aim of the study was to test if an electronic pill dispenser named DoPill(®) improved AAR of schizophrenic patients. Furthermore, we compared AAR obtained by the DoPill(®) and the BARS, in order to verify whether the DoPill(®) provides reliable assessment of medication adherence. METHODS: The DoPill(®) is a smart pill dispenser that beeps and flashes at the appropriate time of the day. Each of its 28 compartments is covered by a plastic lamina that, when taken off, sends a signal to the pharmacist. Patients were randomized to the DoPill(®) or treatment as usual groups for 6 weeks. The BARS was used as a reference measure. RESULTS: Forty-six percent of patients were deemed to be non-adherent with antipsychotic medication. The mean AAR was 67% after 6 weeks. DoPill(®) recorded better AAR than some of those found in the literature and were lower than the BARS estimate we found. CONCLUSION: These results suggest that DoPill(®) is a valid tool that provides more reliable and objective data for the clinician about their patient's adherence, than existing assessment tools like the BARS. Furthermore, the device may help patients successfully manage their medication regimen.

Changing the name of schizophrenia: patient perspectives and implications for DSM-V.

INTRODUCTION: The diagnosis of schizophrenia is increasingly contested by researchers, clinicians, patients and family members. Preeminent researchers proposed its replacement with the salience syndrome concept, arguing for increased validity and less stigmatizing potential. This is the first study exploring the effects on stigma of this nosological proposal. METHODS: TWO STUDIES WERE CONDUCTED: one with 161 undergraduate students regarding their stigmatizing attitudes linked to the label of schizophrenia or salience syndrome, the other involved in-depth qualitative interviews with 19 participants treated in a first episode psychosis program. The interviews explored the subjective validity, acceptability and effects on stigma of a diagnosis of schizophrenia or salience syndrome. RESULTS: Overall, no significant differences were found between labels in study 1. For study 2, the majority of participants preferred a diagnosis of salience syndrome, considering it less stigmatizing mostly because of its novelty and the concealing potential of the new diagnostic entity, though many found it hard to relate to and somewhat difficult to understand. DISCUSSION: Our results suggest that the label change does not impact the stigmatizing potential for individuals who are not familiar with mental illness - they appear to base their attitudes on descriptions rather than the label alone. For those suffering from mental illness, a name change for schizophrenia to "salience syndrome" might offer only a temporary relief from stigma. Claims of de-stigmatizing effects should be grounded in sound scientific models of stigma and ideally in empirical data.

Becoming adherent to antipsychotics: a qualitative study of treatment-experienced schizophrenia patients.

OBJECTIVE: Discontinuation of antipsychotic medication is a pervasive clinical problem in the treatment of patients suffering from psychosis. The aim of this study was to complement a largely quantitative body of research by focusing on patients' perspectives on the topic. METHODS: In-depth semistructured interviews were conducted with 20 persons who have schizophrenia spectrum disorders. Narratives were elicited on illness and medication use and emphasized key turning points, such as periods of nonadherence and illness relapses. RESULTS: Respondents had extensive experience with antipsychotic treatment (15±12 years of treatment). Nineteen (95%) reported at least one extended period of nonadherence. A complex picture of medication use or refusal emerged from patients' descriptions. An array of external factors influenced initiation of medication and treatment maintenance: pressure from family or clinicians, secondary benefits from initiating and maintaining treatment, and a variety of coercive measures. Moreover, personal factors transcended rational models in deciding whether to take medication; patients' responses stressed the importance of trust, emotional reactions, and subjective experiences with medication and stigma. CONCLUSIONS: These findings call into question the validity of a purely voluntaristic model of the use of antipsychotic medication. Its use was part of a long and painful fight with a debilitating disorder, and off-medication periods were essential parts of a learning process.

Early intervention in psychosis: a case study on normal and pathological.

Accumulating evidence suggests that delays in receiving treatment are associated with poorer prognosis and longer periods of unneeded suffering. The duration of untreated psychosis (DUP) is considered to be one of the most important determinants of outcome in the first episode of psychosis. However, the focus on decreasing the length of untreated illness tends to overlook the difficult task of making sense of psychotic experiences during a first episode. Using a qualitative analysis of narratives obtained from interviews with an individual and her husband, we examine what delayed her seeking help, how she became convinced that she needed treatment and what this meant for her and her husband. Additionally, we look at the five-year development of both a literal and a figurative space within which both the subject and her husband came to utilize, whether consciously or unconsciously, the 'stories' of her psychotic experiences to construct a shared and even 'safe' and familiar means of spousal connection. The exploration of this shared space reveals the normative and moral values embedded in the concept of DUP and suggests alternative ways of understanding the help-seeking behaviors in early psychosis.

A prototype approach toward antipsychotic medication adherence in schizophrenia.

Antipsychotic nonadherence in psychotic disorders is a vexing clinical problem. While many risk factors are associated with nonadherence, a risk factor model per se is a poor guide for clinical decisions. We propose a pragmatic clinical prototype approach that incorporates two variables, medication drug attitude and worldview (with regard to mental illness and psychiatric treatment), to create five patient prototypes of adherence: patients with good adherence for the right reasons ("True Believer"), with good adherence for the wrong reasons ("Clinic Trouper"), with reluctant and tenuous adherence ("Reluctant Recruit"), with passive adherence ("The Coffee Guy"), and with unwillingness to take medications ("Constitutional Combatant"). Actual patients can be compared and assigned to one of the prototypes, with the group membership predicting level and character of adherence, and suggesting specific interventions. In this scheme, drug attitude and worldview are key variables for adherence; both can be ascertained during the clinical interview and quantified with rating scales.

Should we treat auditory hallucinations with repetitive transcranial magnetic stimulation? A metaanalysis.

OBJECTIVE: Abnormal activations of neural networks implicated in auditory stimuli processing are hypothesized to generate auditory hallucinations (AH) in schizophrenia spectrum disorders. Because repetitive transcranial magnetic stimulation (rTMS) has the potential to modulate neural network activity, several studies have explored its use in treating medication-resistant AH, with mixed results in small-to-medium patient samples. Our aim is to apply a metaanalytic approach to exploring the efficacy of rTMS in treating medication-resistant AH. METHOD: A search of the electronic databases for studies comparing low-frequency (1 Hz) rTMS over the left temporoparietal cortex to sham stimulation in patients suffering from medication- resistant AH was performed. Our search was completed by cross-referencing the articles, searching the Current Controlled Trials website, and direct contact with relevant researchers. RESULTS: From 265 possible abstracts, 6 parallel-arm, double-blind placebo-controlled and 4 crossover controlled trials, all randomized, matched the inclusion and exclusion criteria (n = 232). The primary outcome measure (effect of active treatment on AH at the end of the treatment) was tested with a random effect model and reached a significant homogeneous ES estimate (Hedges' g = 0.514; P = 0.001; 95CI%, 0.225 to 0.804; Q = 13.022; P = 0.162). CONCLUSIONS: We found that low-frequency rTMS over the left temporoparietal cortex has a medium ES action on medication-resistant AH. This result has implications for understanding the pathophysiology of psychotic symptoms (specifically AH) and supports the use of rTMS as a complementary treatment approach in patients suffering from treatment-resistant AH.

Insight and psychosis: comparing the perspectives of patient, entourage and clinician.

BACKGROUND: The construct of insight in psychosis assumes congruence between patient and clinician views of the meaning of symptoms and experience. Current definitions and measures of insight do not give systematic attention to the impact of interpersonal, cultural and socio-economic contexts. AIMS: We hypothesized that socio-cultural factors influence insight in patients with schizophrenia. METHODS: We tested this hypothesis through comparison of insight in 18 triads, each composed of a patient, a family member and a clinician. The sample consisted of patients who were first diagnosed with psychosis in the last two years, and who were either immigrants from Africa or the Caribbean Islands, or Canadian born. Insight was assessed by analysis of narratives collected from patients, family members and clinicians for a research project on the negotiation of treatment. Each narrative was scored for insight along multiple dimensions with the Extracted Insight Scale (EIS), developed for this project. RESULTS: There was a significant correlation of insight on the EIS between patients and family members (r= 0.51, p= 0.03) but not between patient and clinician or family and clinician. The mean levels of insight across the three groups were comparable. Qualitative analysis of the illness narratives suggested that insight was based on the meanings constructed around psychotic experiences and that the process of interpreting and attributing psychotic experiences reflected each person's cultural background, life experiences, and other social determinants, especially stigma. CONCLUSION: Forms of insight can occur in the context of discordance or disagreement with the clinician's opinion. We present a testable model of the sociocultural determinants of insight that can guide future studies.

Benefits and risks of antipsychotic polypharmacy: an evidence-based review of the literature.

Combination antipsychotic prescription is an increasingly common practice in clinical psychiatry. This clinical practice is at odds with clinical guidelines promoting antipsychotic monotherapy. Moreover, there has been increased concern over the safety profile of atypical antipsychotics in the last 10-15 years. We reviewed the literature on antipsychotic combinations with a focus on safety and efficacy. Multiple electronic database searches were complemented by relevant bibliography cross-checking and expert discussions. The review showed a literature that is dominated by case reports and uncontrolled studies. Polypharmacy was unequally studied, with some recent combinations (i.e. clozapine and risperidone) being extensively, albeit inconclusively, studied and other more commonly used combinations (first- with second-generation agents) receiving little attention. From an evidence-based perspective, further trials of antipsychotic association of sufficient power to address safety issues are needed before recommending any antipsychotic combination. Particular weaknesses of the present literature are low number of participants, lack of adequate control of confounding variables, short duration of experimental follow-up and inadequate monitoring of potential adverse effects.

Insight in first episode psychosis: who is measuring what?

AIMS: To compare different self-administered or clinician-rated insight scales in an FEP population. METHODS: A self-administered measure (Beck Cognitive Insight Scale - BCIS) and clinician-rated scales (Scale of Unawareness of Mental Disorder - SUMD and Positive And Negative Symptoms Scale - PANSS-G12 insight item) were completed by 38 patients with a diagnosis of FEP. RESULTS: The scales had good internal consistency and only the clinician-rated scales were intercorrelated (SUMD - awareness of mental disorder and PANSS-G12 items (r=0.657, P<0.001)). Moreover, we observed a significant association of SUMD and PANSS positive and general subscales and a trend association for BCIS and PANSS negative subscale. CONCLUSION: Differential associations observed between insight and symptoms may suggest different clinical predictive values for each measure. Our results suggest the necessity to qualify the term 'insight' when discussing research results, most notably with respect to who is rating and what aspect of insight is being rated.

Augmentation strategies of clozapine with antipsychotics in the treatment of ultraresistant schizophrenia.

BACKGROUND: Approximately 40% to 70% of neuroleptic-resistant schizophrenic patients are nonresponders to clozapine. Several clozapine augmentation strategies have come into clinical practice although often without evidence-based support. Among these strategies, the combined use of clozapine with another antipsychotic has been reported for up to 35% of patients receiving clozapine. OBJECTIVE: The purposes of the present work were to (1) review the available literature on the efficacy and safety of the clozapine augmentation with another antipsychotic using a MEDLINE search of the literature from 1978 to December 2005 and (2) to propose an operational definition of schizophrenia refractory to clozapine ("ultraresistant schizophrenia") for the implementation and homogenization of future therapeutic trials. CONCLUSION: Case controls and open clinical trials largely dominate the literature, and there are only 4 double-blind studies of clozapine augmentation with antipsychotics. The results of these studies are somewhat discrepant. Moreover, the heterogeneity of definitions of resistance to clozapine, of outcome measures and of dose and duration of pharmacological trials is a major limitation for drawing conclusions.

Somatic augmentation strategies in clozapine resistance--what facts?

BACKGROUND: Polypharmacy without evidence-based support is sometimes needed for patients treated with 40% to 70% clozapine who are clozapine nonresponders. Several somatic augmentation strategies are proposed in the scientific literature, with different levels of evidence for safety and efficacy. OBJECTIVES: The purpose of the present study is to review the available literature on the efficacy and safety of clozapine augmentation with somatic agents other than antipsychotics. The following classes of agents are considered: (1) mood stabilizers, (2) antidepressants, (3) electroconvulsive therapy and repetitive transcranial magnetic stimulation, (4) glutamatergic agents, (5)fatty acids supplements, and (6) benzodiazepines. RESULTS: Case controls and small-size clinical trials largely dominate the literature, limiting the power to draw conclusions concerning safety issues and the meaning of negative studies. Moreover, variable definitions of clozapine resistance, heterogeneous outcome measures, and short duration of treatment trials are additional limitations. CONCLUSION: Generally, adjunctive strategies for clozapine-resistant patients remain based on scarce evidence of efficacy and significant safety concerns. Low-frequency repetitive transcranial magnetic stimulation, fatty acids supplements, and mirtazapine showed good tolerability and some efficacy, but the results need replication.

The paradox of quetiapine in obsessive-compulsive disorder.

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

[Antipsychotic drugs. Risk factors for diabetes]. / Les médicaments antipsychotiques. Facteurs de risque de diabète.

ANTIPSYCHOTICS AND DIABETES: After 50 years' use of antipsychotics, it is pertinent to draw-up a circumspect review of the side effects of these psychotropic agents. Moreover, few articles have attempted to elucidate the relationship between the monitoring of carbohydrate metabolism and the prescription of this type of medication. SEVERAL MECHANISMS AT THE ORIGIN OF AN IMBALANCE IN GLYCAEMIA: Antipsychotics, notably the atypical forms, represent an additional factor of risk for developing diabetes. The weight gain secondary to this treatment plays an important part in this imbalance, but other mechanisms may also contribute. DEPENDING ON THE TYPE OF ANTIPSYCHOTIC: Our present knowledge is insufficient to be able to quantify the effect of each atypical antipsychotic on diabetes. The only tendency that has been reproduced in several studies concerns the increased risk associated with dibenzodiazepine antipsychotics (clozapine and olanzapine), compared with the other antipsychotics.

[Diabetes and schizophrenia, which links?]. / Diabète et schizophrénie, quels liens?

UNLABELLED: WHAT IS OBSERVED: Epidemiology and clinical practice show an increased prevalence of diabetes in schizophrenic patients, preceding even the use of antipsychotics. Several patho-physiological mechanisms have been proposed to explain the phenomenon, although none is completely satisfactory. SEVERE CONSEQUENCES: Diabetic schizophrenics exhibit a significantly greater number of other physical diseases than non-diabetic schizophrenic patients. These diseases are at the origin of early mortality and reduced quality of life. THE NEED FOR SCREENING: Schizophrenic patients should be included in the groups of those at risk for diabetes, together with patients treated with anti-psychotics. Diabetes is diagnosed if fasting blood sugar is>7.0 mmol/L and a glucose tolerance test>11,1 mmol/L. IN PRACTICE: The epidemiology and extent of the impact on mortality and morbidity of the association between schizophrenia and diabetes mellitus requires particular attention of the practitioners and the screening for diabetes, its prevention and treatment must be conducted according to regularly updated guidelines.