Hans Oh

Sustaining motivational interviewing: a meta-analysis of training studies

BACKGROUND AND AIMS Previous research indicates that motivational interviewing (MI) skills decline over time among participants in training workshops when post-workshop feedback and coaching are not provided. This study explored moderators of skill retention among trainees learning MI mainly for substance use disorder treatment in real-world treatment settings, including workshop enhancements and type and dose of post-workshop feedback and coaching. METHODS A meta-analysis of training studies was conducted with studies that reported MI skills using observational measures and that included trainees from real-world agency settings. Standardized change scores were calculated to indicate the magnitude of pre-post training change in MI skills; standardized change scores from post-training to 3 and 6+ months follow-up were calculated to indicate the sustainability of training gains over time. Effect sizes were aggregated using random effects models. RESULTS Twenty-one papers that reported the effects of MI training on agency staff were included in this review. Across studies, training yielded gains in MI skills (d = 0.76). Studies that did not include feedback and/or coaching reported eroding skills over a 6-month follow-up (d = -0.30), whereas post-workshop feedback/coaching sustained skills (d = 0.03). Effects of post-workshop feedback/coaching were moderated by frequency, duration and length of training. Moreover, studies reporting low levels of attrition from training protocols showed small increases in skills over the 6-month follow-up period (d = 0.12), whereas studies with high attrition showed skill erosion (d = -0.29). CONCLUSIONS On average, three to four feedback/coaching sessions over a 6-month period sustain skills among trainees for motivational interviewing, mainly for substance use disorder treatment. However, high rates of attrition from feedback/coaching contributes to post-workshop skill erosion.

Treatment Seeking and Unmet Need for Care Among Persons Reporting Psychosis-Like Experiences

OBJECTIVE Psychosis-like experiences may be clinically significant given their demonstrated associations with concurrent psychological distress and the later development of diagnosable psychotic disorders. Prior studies of treatment for psychosis-like experiences have yielded conflicting results. The aims of this study were to investigate help seeking and need for care among individuals with psychosis-like experiences in a large general population sample. METHODS Data from the Collaborative Psychiatric Epidemiology Surveys (N=10,541) were used to examine help-seeking behaviors among survey respondents who reported psychosis-like symptoms over a 12-month period. Adjusted odds ratios were calculated for a variety of help-seeking variables, with control for demographic factors and co-occurring psychiatric conditions. RESULTS Among the 10,541 respondents, 3.4% reported a psychosis-like experience in the past 12 months. Respondents who reported psychosis-like experiences were more than twice as likely as those who did not to seek treatment. Those who reported such experiences but who did not seek treatment were more likely to have felt the need for or to have been encouraged by others to seek treatment and less likely to have felt that they had no psychiatric problem. Associations with unmet need for care were largely attributable to co-occurring psychiatric disorders. CONCLUSIONS Respondents with psychosis-like experiences had elevated rates of help seeking, as well as significant unmet clinical need among those not in treatment.

Acculturative stress and psychotic-like experiences among Asian and Latino immigrants to the United States

Previous studies have shown variation in the prevalence and incidence of psychosis across immigrant groups, but the underlying mechanisms are not fully understood. Stress related to acculturation may increase risk for psychosis among immigrant groups. In this study we examine the association between acculturative stress and psychotic-like experiences in a sample of Latino- and Asian-American immigrants to the United States in the National Latino and Asian American Study (n=2434). Acculturative stress was associated with visual and auditory hallucinations among Asians, but only with hearing voices among Latinos. Increased risk for psychotic-like experiences among Latinos was primarily associated with younger age of immigration. Acculturative stress appears to be a promising candidate mechanism explaining the relationship between immigration and psychosis, particularly among Asian Americans. Ethnic differences may reflect variability between groups that integrate more readily into the host culture and those that are subject to greater discrimination and environmental adversity.

Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States

OBJECTIVE The objective of this study was to examine the relationship between perceived discrimination and psychotic experiences (PE) using validated measures of discrimination and a racially/ethnically diverse population-level sample. METHODS Data were drawn from two population-level surveys (The National Latino and Asian American Survey and The National Survey of American Life), which were analyzed together using survey weights and stratification variables. The analytic sample (N=8990) consisted of Latino, Asian, African-American, and Afro-Caribbean adults living in the United States. Separate unadjusted and adjusted multivariable logistic regression models were used, first to examine the crude bivariate relationship between perceived discrimination and PE, and second to examine the relationship adjusting for demographic variables. Adjusted logistic regression models were also used to examine the relationships between perceived discrimination and specific sub-types of PE (auditory and visual hallucinatory experiences, and delusional ideation). RESULTS When compared to individuals who did not report any discrimination, those who reported the highest levels of discrimination were significantly more likely to report both 12-month PE (Adjusted OR=4.590, p<0.001) and lifetime PE (adjusted OR=4.270, p<0.001). This held true for visual hallucinatory experiences (adjusted OR=3.745, p<0.001), auditory hallucinatory experiences (adjusted OR=5.649, p<0.001), and delusional ideation (adjusted OR=7.208, p<0.001). CONCLUSION Perceived discrimination is associated with the increased probability of reporting psychotic experiences in a linear Fashion in the US general population.

Risk and functional significance of psychotic experiences among individuals with depression in 44 low- and middle-income countries

BACKGROUND Studies on whether the co-occurrence of psychotic experiences (PEs) and depression confers a more pronounced decrement in health status and function compared with depression alone are scarce in the general adult population. METHOD Data on 195 479 adults aged ⩾18 years from the World Health Survey were analysed. Using the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI), depression in the past 12 months was categorized into four groups: depressive episode, brief depressive episode, subsyndromal depression, and no depression. Past 12-month psychotic symptoms were assessed using four questions on positive symptoms from the CIDI. Health status across seven domains (cognition, interpersonal activities, sleep/energy, self-care, mobility, pain/discomfort, vision) and interviewer-rated presence of a mental health problem were assessed. Multivariable logistic and linear regression analyses were performed to assess the associations. RESULTS When compared with those with no depression, individuals with depression had higher odds of reporting at least one PE, and this was seen across all levels of depression severity: subsyndromal depression [odds ratio (OR) 2.38, 95% confidence interval (CI) 2.02-2.81], brief depressive episode (OR 3.84, 95% CI 3.31-4.46) and depressive episode (OR 3.75, 95% CI 3.24-4.33). Having coexisting PEs and depression was associated with a higher risk for observable illness behavior and a significant decline in health status in the cognition, interpersonal activities and sleep/energy domains, compared with those with depression alone. CONCLUSIONS This coexistence of depression and PEs is associated with more severe social, cognitive and sleep disturbances, and more outwardly apparent illness behavior. Detecting this co-occurrence may be important for treatment planning.

Stress Sensitivity and Psychotic Experiences in 39 Low- and Middle-Income Countries

Stress has a central role in most theories of psychosis etiology, but the relation between stress and psychosis has rarely been examined in large population-level data sets, particularly in low- and middle-income countries. We used data from 39 countries in the World Health Survey (n = 176 934) to test the hypothesis that stress sensitivity would be associated with psychotic experiences, using logistic regression analyses. Respondents in low-income countries reported higher stress sensitivity (P < .001) and prevalence of psychotic experiences (P < .001), compared to individuals in middle-income countries. Greater stress sensitivity was associated with increased odds for psychotic experiences, even when adjusted for co-occurring anxiety and depressive symptoms: adjusted odds ratio (95% CI) = 1.17 (1.15-1.19) per unit increase in stress sensitivity (range 2-10). This association was consistent and significant across nearly every country studied, and translated into a difference in psychotic experience prevalence ranging from 6.4% among those with the lowest levels of stress sensitivity up to 22.2% among those with the highest levels. These findings highlight the generalizability of the association between psychosis and stress sensitivity in the largest and most globally representative community-level sample to date, and support the targeting of stress sensitivity as a potential component of individual- and population-level interventions for psychosis.

Psychotic symptoms predict health outcomes even after adjusting for substance use, smoking and co-occurring psychiatric disorders: findings from the NCS-R and NLAAS

Psychotic disorders are associated with medical pathologies, and a recent study has shown that these associations extend into the sub-threshold regions of psychosis. Moreno et al (1) found that psychotic symptoms conferred risk for several lifetime physical health problems, including angina pectoris/cardiovascular problems, asthma/pulmonary problems, arthritis, tuberculosis, vision/hearing problems, and mouth/teeth problems. Also, psychotic symptoms were related to risky lifestyle behaviors, such as alcohol consumption and smoking, although these outcomes may have actually functioned as potential mediators. Further, psychotic symptoms are often accompanied by other psychiatric disorders (e.g., 2), which may likewise mediate relationships with medical conditions. Building on the work of Moreno et al, we used data from the U.S. to test whether substance use, smoking and co-occurring psychiatric disorders mediated the relationship between psychotic symptoms and physical health problems. We analyzed two surveys conducted in the U.S.: the National Comorbidity Survey – Replication (NCS-R), using a nationally representative sample; and the National Latino and Asian American Study (NLAAS), using a national area probability sample with supplements for adults of Latino and Asian national origin. Both surveys adopted multi-stage clustered sampling designs. Details on the sampling strategy and interview procedures have been provided elsewhere (3). Respondents were included if they were assessed by the non-affective psychosis screen of the Composite International Diagnostic Interview (CIDI), which was administered to a random sub-sample of the respondents of the NCS-R (n+2322), and all respondents of the NLAAS (n+4644). Participants were excluded if they were missing data for any of the variables of interest. The final sample for this study consisted of 6,917 respondents. Respondents were asked to report the lifetime presence of six specific psychotic experiences, which included two types of hallucinatory experiences (visual and auditory) and four types of delusion-like experiences (thought insertion, thought control, telepathy, and feelings of persecution). Responses were excluded if the experience took place in the context of falling asleep, dreaming or substance use. Respondents were asked (yes/no) if they had ever had the following five conditions in their lifetimes: arthritis/rheumatism, chronic back/neck problems, other chronic pain, stroke, and heart disease. Demographic covariates included age, sex, ethnicity, income-to-poverty ratio, education, insurance coverage, and region of the country. Substance use included diagnoses of alcohol abuse and dependence, as well as drug abuse and dependence, ascertained through the CIDI. Co-occurring psychiatric disorders included CIDI diagnoses of anxiety disorders (agoraphobia with and without panic disorder, generalized anxiety disorder, panic attacks, panic disorder, post-traumatic stress disorder, and social phobia) and mood disorders (major depressive episode, major depressive disorder, and dysthymia). Smoking was measured by an item that prompted respondents to identify with four mutually exclusive categories: “current smoker”, “ex-smoker”, “only a few times”, or “never”. “Current smoker” and “ex-smoker” were combined, as well as “only a few times” and “never”, to form a dichotomous variable. All analyses were conducted using the complex sample features of STATA SE 13. Analyses were two-tailed, alpha+0.05. Design-based analyses were used to estimate standard errors that accounted for the complex multistage clustered design of the NCS-R and NLAAS samples. All statistical estimates were weighted to account for individual-level sampling factors, including non-response and unequal probabilities of selection. Odds ratios were calculated using blocked hierarchical logistic regression. First, bivariate logistic regression analyses were used to determine the impact of psychotic experiences on health outcomes. In the second block, the logistic regression analyses were repeated with adjustments for potential demographic confounders. In the third block, analyses were repeated with adjustments for demographic confounders and substance use. In the fourth block, clinical variables were added to the demographic variables to determine whether the effects of psychotic experiences were independent of other mental health conditions. In the fifth block, smoking was added to demographic variables. The final block consisted of demographic variables and all potential mediators. Analyses were repeated with the exclusion of individuals who self-reported a history of a schizophrenia diagnosis, and results did not vary significantly. After adjusting for demographics, psychotic experiences were associated with the increased likelihood of reporting arthritis/rheumatism (OR: 1.80, p+0.000), back/neck problems (OR: 1.98, p+0.000), headache (OR: 2.08, p+0.000), heart disease (OR: 2.36, p+0.024), other chronic pain (OR: 1.94, p+0.001), and stroke (OR: 1.72, p+0.143). Based on separate models adjusted for individual confounds – co-occurring psychiatric disorders (affective and anxiety), smoking, and substance use – we found that each of the confounds partially mediated the associations between psychotic experiences and physical health problems, especially co-occurring depressive and anxiety factors (data available upon request). The full model (adjusted for demographic variables and all potential mediators) showed that psychotic experiences still predicted some health outcomes: arthritis/rheumatism (OR: 1.50, p+0.001), back/neck problems (OR: 1.56, p+0.006), headache (OR: 1.64, p+0.000), and heart disease (OR: 2.14, p+0.023). The effect was no longer statistically significant in the full model for other chronic pain (OR: 1.44, p+0.060) and stroke (OR: 1.40, p+0.395). In conclusion, psychotic experiences were associated with negative health outcomes independent of a psychotic disorder diagnosis, and the effect persisted for arthritis/rheumatism, back/neck problems, headache, and most strongly for heart disease, even with the inclusion of other mediating variables, among which co-occurring psychiatric disorders proved to be the strongest. These findings support screening for health conditions (particularly heart disease) among individuals with psychotic symptoms, regardless of psychiatric diagnosis.

Prevalence, demographic variation and psychological correlates of exposure to police victimisation in four US cities

Aims Victimisation by the police is purported to be widespread in cities in the USA, but there is limited data on police-public encounters from community samples. This is partly due to an absence of measures for assessing police violence exposure from the standpoint of civilians. As such, the demographic distribution and mental health correlates of police victimisation are poorly understood. The aims of this study were to present community-based prevalence estimates of positive policing and police victimisation based on assessment with two novel measures, and to test the hypotheses that (1) exposure to police victimisation would vary across demographic groups and (2) would be associated with depression and psychological distress. METHODS The Survey of Police-Public Encounters study surveyed adults residing in four US cities to examine the prevalence, demographic distribution and psychological correlates of police victimisation. Participants (N = 1615) completed measures of psychological distress (K-6 scale), depression (Patient Health Questionnaire 9) and two newly constructed measures of civilian-reported police-public encounters. Both measures were developed to assess police victimisation based on the WHO domains of violence, which include physical violence (with and without a weapon, assessed separately), sexual violence (inappropriate sexual contact, including public strip searches), psychological violence (e.g., threatening, intimidating, stopping without cause, or using discriminatory slurs) and neglect (police not responding when called or responding too late). The Police Practices Inventory assesses lifetime history of exposure to positive policing and police victimisation, and the Expectations of Police Practices Scale assesses the perceived likelihood of future incidents of police victimisation. Linear regression models were used to test for associations between police-public encounters and psychological distress and depression. RESULTS Psychological violence (18.6%) and police neglect (18.8%) were commonly reported in this sample and a substantial minority of respondents also reported more severe forms of violence, specifically physical (6.1%), sexual (2.8%) and physical with a weapon (3.3%). Police victimisation was more frequently reported by racial/ethnic minorities, males, transgender respondents and younger adults. Nearly all forms of victimisation (but not positive policing) were associated with psychological distress and depression in adjusted linear regression models. CONCLUSIONS Victimisation by police appears to be widespread, inequitably distributed across demographic groups and psychologically impactful. These findings suggest that public health efforts to both reduce the prevalence of police violence and to alleviate its psychological impact may be needed, particularly in disadvantaged urban communities.

Epidemiology of depression with psychotic experiences and its association with chronic physical conditions in 47 low- and middle-income countries

BACKGROUND The co-existence of depression and psychotic experiences (PEs) is associated with more pronounced adverse health outcomes compared to depression alone. However, data on its prevalence and correlates are lacking in the general adult population, and there is no published data on its association with chronic physical conditions. METHOD Cross-sectional, community-based data from 201 337 adults aged ⩾18 years from 47 low- and middle-income countries from the World Health Survey were analyzed. The presence of past 12-month PE and DSM-IV depression was assessed with the Composite International Diagnostic Interview (CIDI). Information on six chronic medical conditions (chronic back pain, edentulism, arthritis, angina, asthma, diabetes) were obtained by self-report. Multivariable logistic regression analysis was performed. RESULTS The crude overall prevalence of co-morbid depression/PEs was 2.5% [95% confidence interval (CI) 2.3-2.7%], with the age- and sex-adjusted prevalence ranging from 0.1% (Sri Lanka, Vietnam) to 9.03% (Brazil). Younger age, urban setting, current smoking, alcohol consumption, and anxiety were significant correlates of co-existing depression/PEs. Co-occurring depression/PEs was associated with significantly higher odds for arthritis, angina, and diabetes beyond that of depression alone after adjusting for sociodemographics, anxiety, and country, with odds ratios (depression/PEs v. depression only) being: arthritis 1.30 (95% CI 1.07-1.59, p = 0.0086); angina 1.40 (95% CI 1.18-1.67, p = 0.0002); diabetes 1.65 (95% CI 1.21-2.26, p = 0.0017). CONCLUSIONS The prevalence of co-existing depression/PEs was non-negligible in most countries. Our study suggests that when depression/PE or a chronic condition (e.g. arthritis, angina, diabetes) is detected, screening for the other may be important to improve clinical outcomes.

Sleep disturbances are associated with psychotic experiences: Findings from the National Comorbidity Survey Replication

Sleep disturbances have been linked to psychotic experiences in the general adult populations of multiple countries, but this association has yet to be confirmed in the United States using robust diagnostic measures. We analyzed a subsample (n=2304) of the National Comorbidity Survey Replication, and found that when compared with those who did not report any sleep problems, individuals with sleep disturbances lasting two weeks or longer over the past 12months were significantly more likely to report at least one psychotic experience during that same time frame. Specifically, difficulty falling asleep, waking up during the night, early morning awakenings, and feeling sleepy during the day were each associated with greater odds of reporting psychotic experiences over the past year after controlling for socio-demographic variables. However, only difficulty falling asleep and early morning awakenings were still significant after adjusting for DSM comorbid disorders. Reporting three or four types of sleep disturbances was especially predictive of psychotic experiences. Our findings underscore the importance of detecting and reducing sleep problems among individuals who report PE.