Neil Krishan Aggarwal

Prevalence of concomitant oral antipsychotic drug use among patients treated with long-acting, intramuscular, antipsychotic medications.

Objective Long-acting injectable (LAI) antipsychotic drugs are viewed as monotherapeutic alternatives to oral medications to promote medication adherence, but there have been no descriptive studies of concomitant use of oral and LAI medications. Methods A list of all patients receiving services from the Connecticut Mental Health Center from July 1, 2009, to June 30, 2010, was obtained from center administrative records, and those carrying an initial intake diagnosis of schizophrenia or schizoaffective disorder were identified. All team leaders were approached, and all clinicians were asked to identify patients on their case load prescribed LAIs during the time interval above. Also, all internal and external pharmacy orders were reviewed. Concomitancy was defined as simultaneous oral and LAI antipsychotic use at any time from July 1, 2009, to June 30, 2010. Data were culled from the medical records using a form (available on request) that recorded current LAI antipsychotic, reasons for LAI use, length of time on LAI, monthly dosage, and all concomitant oral antipsychotics, antidepressants, and anxiolytic agents. Results Among 124 patients on LAI medications, 57 (46%) received concomitant oral and LAI antipsychotics: 27 (47%) were prescribed LAI haloperidol, 19 (33%) LAI fluphenazine, and 11 (19%) risperidone microspheres. Logistic regression showed greater use of oral antipsychotic for both Hispanic ethnicity (odds ratio, 3.8; 95% confidence interval, 1.3–10.8) and alcohol abuse/dependence (odds ratio, 6.5; 95% confidence interval, 1.3–31.9), with no significant differences on other variables. There were no significant differences between LAI agents in rates of use of concomitant oral antipsychotic, anticholinergic, sedative/hypnotic, or mood stabilizer. Patients were more likely to be prescribed concomitant oral preparations of their LAI agent than another oral antipsychotic. Higher dosing of LAI treatments was associated with a significantly greater likelihood of use of oral psychotropics and anticholinergics. Conclusions Almost one half of patients prescribed LAI antipsychotics receive oral antipsychotics and other oral psychotropics. This challenges the notion that LAIs are used as monotherapy in real-world settings. Concomitant oral and LAI antipsychotic prescriptions may represent a common practice of polypharmacy that merits further investigation.

Comparing the PANSS in Chinese and American inpatients: cross-cultural psychiatric analyses of instrument translation and implementation.

This article compares data from the Positive and Negative Syndrome Scale (PANSS) collected from Chinese and American inpatients diagnosed with schizophrenia to show how patterned differences in item ratings may reflect cultural attitudes of the raters. The Chinese sample (N=553) was based on consecutive admissions to four academic hospitals in Changsha, China. Only patients ill for 3 or more years were included in the analysis to match the chronically ill sample represented in the US CATIE sample. A total of 261 PANSS assessments were completed during a month when CATIE subjects had been hospitalized for 15 days or more to optimize equivalence of the US and Chinese samples. Controlling for age and gender, the total PANSS and the three sub-scores were all significantly lower in the Chinese than in the US CATIE sample by 5-8% (all p<.05). However, on 9 items, the Chinese sample scored 10-30% higher than the US sample (all p<.05) and on 5 items they scored over 20% higher (all p<.0001). These items rated increased hostility, poorer attention, lack of judgment and insight, disturbance of volition, and poorer impulse control. We ascribe these differences to cultural variations in the ways individuals relate to others in their social environment within Chinese and American societies.

Race and Long-Acting Antipsychotic Prescription at a Community Mental Health Center: A Retrospective Chart Review

OBJECTIVE There has been concern that racial minorities are disproportionately prescribed long-acting injectable antipsychotic drugs. METHOD Comprehensive administrative data and clinician survey were used to identify all patients with a DSM-IV diagnosis of schizophrenia who received long-acting antipsychotic prescriptions from July 2009 to June 2010 at a community mental health center. Charts were reviewed retrospectively to validate long-acting antipsychotic prescription (eg, medication, dosage) and merged with administrative data from all center patients documenting sociodemographic characteristics (ie, age, race, gender) and comorbid diagnoses. We used bivariate χ2, t tests, and multivariate logistic regression to compare the subsample of patients receiving long-acting injectable drugs (n = 102) to patients not receiving long-acting injectable drugs (n = 799) who were diagnosed with schizophrenia for the same period. RESULTS White patients were significantly less likely to receive long-acting antipsychotic prescriptions than minority patients (OR = 0.52, P < .007); ie, nonwhites were 1.89 times more likely to receive such drugs. Age, gender, and comorbid diagnoses, including substance abuse, were unrelated to long-acting injectable prescription, and race/ethnicity was not associated with use of specific agents (haloperidol decanoate, fluphenazine decanoate, or risperidone microspheres) (P = .73). CONCLUSIONS Racial minorities are more likely than other patients with schizophrenia to receive long-acting injectionable antipsychotics, a finding that suggests their prescribers may consider them less adherent to antipsychotic prescriptions.

Reassessing Cultural Evaluations in Geriatrics: Insights from Cultural Psychiatry

Current cultural competency models in geriatrics represent positive developments but may focus disproportionately on group‐level information without attending to intracultural, individual variations. This article reviews these limitations and introduces the cultural formulation from psychiatry as a more‐thorough assessment strategy. By focusing on the patients relationships with cultural identity, illness explanations, social networks, and the physician, a cultural formulation designed for geriatrics may help clinicians plan treatment and follow‐up in a more‐comprehensive and ‐patient‐centered way. Detailed case studies illustrate its potential applications within geriatrics.

Rater evaluations for psychiatric instruments and cultural differences: the positive and negative syndrome scale in China and the United States.

Abstract This article compares Positive and Negative Syndrome Scale (PANSS) data from Chinese and American inpatients with chronic schizophrenia to show how differences in item ratings may reflect cultural attitudes of raters. The Chinese sample (N = 504) came from Beijing Huilongguan Hospital. The American sample came from 268 PANSS assessments of Clinical Antipsychotic Trials of Intervention Effectiveness subjects hospitalized for 15 days or more to optimize equivalence of the samples. When controlling for age and sex, the Chinese sample scored significantly lower for total score by 25% (p < 0.0001), for the positive subscale by 35% (p < 0.0001), and on the general subscale by 32% (p < 0.0001) but not significantly different on the negative subscale score (+0.26%; p = 0.76). However, the Chinese sample scored 26% higher on the item on poor rapport (p < 0.0001), 10.2% higher on passive social withdrawal (p = 0.003), and most notably 46% higher on the item on lack of judgment and insight (p < 0.0001). These results remain broadly consistent across sex subgroup analyses. Differences seem to be best explained by both cultural differences in patient clinical presentations and varying American and Chinese cultural values affecting rater judgment.

KASHMIRIYAT AS EMPTY SIGNIFIER

The disputed status of Jammu and Kashmir represents the unfinished business of the Partition of India and Pakistan. This essay examines how claims to Kashmir by India, Pakistan, the All Parties Hurriyat Conference (APHC) and the Kashmiri Pandits influence usage of the term ‘Kashmiriyat’ (i.e. the ethos of being Kashmiri). The term is frequently invoked with inconsistent meaning. Kashmiriyat is analysed, through linguistic and semiotic theories of the ‘empty signifier’, to identify which groups are present and absent within sociopolitical discourses.

VIOLATIONS OF PAROLE: LANGUAGE, RELIGION, AND POWER AMONG THE MODERN UDASI MOVEMENT AND THE SGPC

This article explores a subaltern framework to examine language, religion, and power among contemporary Sikh movements, such as the Udasis, that oppose the Shiromani Gurudwara Prabhandak Committee (SGPC). From the late nineteenth century, the Punjab environment progressively communalized as religious groups competed internally and externally to win supporters and define outsiders. Emblematic of these processes in Sikhism are those affirming ties to Hinduism, such as the Udasis, and those seeking a separate religious identity, such as the Tat Khalsa Singh Sabha. This paper begins with an overview of constructions of Hinduism and Sikhism in the colonial period. Next, the theory of parole is developed to trace the relationships among language, religion, and power transacted through speech. Finally, the SGPCs portrayals of the Udasis and modern Udasi responses are presented. The Udasis exemplify how certain sects fell outside of epi-colonial religious demarcations in the Punjab that progressed toward a single Sikh identity. As a theory linking language and power, parole surpasses the classification of religious groups as ‘orthodox’ and ‘heterodox’ to uncover histories where communities define Self and Other.

Diagnostic reasoning in Nizāmī ‘Arūzī’s Four Discourses

Background Most studies on medical reasoning focus on contemporary allopathic practitioners. Here, the significance of diagnostic sense in Nizāmī ‘Arūzī’s Four Discourses (Chahār Maqāle), an influential text that circulated widely throughout the Islamic world, is explored. Methods After a brief introduction, key passages are translated on how doctors should cultivate analytical skills. Results Nizāmī ‘Arūzī cites three sources of diagnostic authority: (1) education in the texts of medical experts, (2) formal logic and (3) belief in the power of God. Conclusions ‘Arūzī’s methods, though rooted in a religious faith that may seem foreign to contemporary doctors and educators, has much to recommend regarding its clarity of approach, its high ethical standards and expectations of doctors, and its commitment to best practices for the patient. Crosscultural studies of medical education and professionalism can offer valuable insights by demonstrating how doctors across history and geography have grappled with the common concerns of diagnosis and treatment.

Denial in Patient–Physician Communication among Patients with Cancer

In this chapter, we discuss the significance of the psychological mechanism of denial in cancer care. We review relevant research literature on the topic, supplemented by clinical literature and personal vignettes. We then discuss key themes in regard to denial in oncology care—the impact of denial on the patient–doctor relationship; denial as a mechanism that “hides” the reasons individuals employ it; denial as an entity with clinical, personal, social, and cultural complexity; physician denial; and physician and family member collusion in the patient’s denial—and offer communication strategies to help address the challenge of denial in cancer care.

How are Suicide Bombers Analysed in Mental Health Discourse? A Critical Anthropological Reading

This paper complicates the notion of the suicide bomber as represented in mental health literature. Most authors apply Western psychiatric concepts to understand suicide bombers without accounting for value differences around life and death or terrorism and martyrdom. Accordingly, these researchers replicate arguments to explain individual behaviour from a particular epistemological perspective. In contrast, critical approaches to this literature can expose the worldviews of the analysers and the analysed to devise sounder interpretations. This paper scrutinises mental health discourse on suicide bombing to ask: (1) What do we learn about the authors of suicide bombers in these articles? (2) How do their analyses demonstrate the relationship between knowledge and power? These conclusions can enable researchers to reduce biases and devise behavioural models that more accurately reflect the realities of their subjects.