Richard McCormick

Higher brain blood flow at amygdala and lower frontal cortex blood flow in PTSD patients with comorbid cocaine and alcohol abuse compared with normals.

Posttraumatic stress disorder (PTSD) patients with histories of cocaine and alcohol abuse (CA-PTSD) were compared with normal volunteers. Positron emission tomography (PET) scans with 15O-butanol were used to compare regional cerebral blood flow (rCBF) between the groups during rest and during an auditory continuous performance task (ACPT). CA-PTSD patients had significantly higher rCBF in right amygdala and left parahippocampal gyrus than normals during the ACPT. Normals had higher rCBF at frontal cortex during the resting scan and during the ACPT. The role of the amygdala in attention and fear conditioning suggests that increased amygdala rCBF may be related to clinical features of PTSD. Cocaine use may be associated with increased amygdala rCBF in PTSD patients. Amygdala and frontal cortex attention system components may be reciprocally related and their relative contributions to processing of neutral stimuli perturbed in CA-PTSD.

Alcohol Consumption Decisions Among Nonabusing Drinkers Diagnosed with Hepatitis C An Exploratory Sequential Mixed Methods Study

Most studies of decisions to curtail alcohol consumption reflect experiences of abusing drinkers. An exploratory sequential research design is used to explore the applicability of this research to the experience of nonabusing drinkers advised to curtail alcohol consumption after a hepatitis C diagnosis. A qualitative component identified 17 new decision factors not reflected in an inventory of factors based on synthesis of existing scales. Qualitative data were triangulated by supplementing semistructured interviews with Internet postings. A quantitative component estimated prevalence and association with current drinking of these new decision factors. Patients who quit drinking tended to attribute postdiagnosis drinking to occasional triggers, whereas patients who were still drinking were more likely to endorse rationales not tied to specific triggers.

Communicating About Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives

BackgroundAbstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.ObjectiveThis study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.DesignWe conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.ResultsWe found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing “stop completely” were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in “medical language” than were GI providers.ConclusionsTo make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

Associations between comorbid anxiety, diabetes control, and overall medical burden in patients with serious mental illness and diabetes

Objective While previous work has demonstrated elevation of both comorbid anxiety disorders and diabetes mellitus type II in individuals with serious mental illness, little is known regarding the impact of comorbid anxiety on diabetes mellitus type II outcomes in serious mental illness populations. We analyzed baseline data from patients with serious mental illness and diabetes mellitus type II to examine relationships between comorbid anxiety, glucose control as measured by hemoglobin A1c score, and overall illness burden. Methods Using baseline data from an ongoing prospective treatment study involving 157 individuals with serious mental illness and diabetes mellitus type II, we compared individuals with and without a comorbid anxiety disorder and compared hemoglobin A1c levels between these groups to assess the relationship between anxiety and management of diabetes mellitus type II. We conducted a similar analysis using cumulative number of anxiety diagnoses as a proxy for anxiety load. Finally, we searched for associations between anxiety and overall medical illness burden as measured by Charlson score. Results Anxiety disorders were seen in 33.1% (N = 52) of individuals with serious mental illness and diabetes mellitus type II and were associated with increased severity of depressive symptoms and decreased function. Hemoglobin A1c levels were not significantly different in those with or without anxiety, and having multiple anxiety disorders was not associated with differences in diabetes mellitus type II control. However, depressive symptoms were significantly associated with higher hemoglobin A1c levels. Neither comorbid anxiety nor anxiety load was significantly associated with overall medical burden. Conclusion One in three people with serious mental illness and diabetes mellitus type II had anxiety. Depressive symptoms were significantly associated with Hb1Ac levels while anxiety symptoms had no relation to hemoglobin A1c; this is consistent with previously published work. More studies are needed to better understand the relationship between depression, anxiety, and health management in people with serious mental illness and diabetes mellitus type II.

Clinical Characteristics of Individuals With Serious Mental Illness and Type 2 Diabetes

OBJECTIVE Data from 157 individuals with serious mental illness and comorbid diabetes enrolled in an ongoing treatment study were used to examine clinical correlates of diabetes control. METHODS Factors assessed included depressive symptoms (Montgomery-Åsberg Depression Rating Scale), global psychopathology severity (Brief Psychiatric Rating Scale), and glycosylated hemoglobin (HbA1c), a biomarker of diabetes control. RESULTS Seventy-seven participants had depression, 40 had schizophrenia, and 40 had bipolar disorder. Most were moderately to severely depressed with poor diabetes control. No correlation between diagnosis and diabetes control was found after adjustment for gender, race, health literacy, diabetes duration, and diabetes knowledge. Greater depression severity and longer diabetes duration were related to poorer diabetes control. Lower severity of global psychopathology was related to poorer diabetes control, perhaps because of overall low levels of psychosis and mania. CONCLUSIONS People with serious mental illness and diabetes face multiple challenges, which, along with severe depression, may impede diabetes self-management.

The long-term relationships between the motivation for change and alcohol use severity among patients with severe and persistent mental illness.

Abstract This study examined the long-term relationship of changes in the motivation to remedy alcohol abuse to alcohol use severity among patients with a dual diagnosis of substance abuse disorder and severe and persistent mental illness. Linear regression analyses showed that patients who increasingly recognized alcohol use problems over a 9-month period exhibited significantly greater alcohol use severity at 9 months and a significant increase in alcohol use severity over time. Moreover, patients who became increasingly determined to take actions against alcohol use over a 9-month period exhibited significantly lower alcohol use severity at 9 months and a significant decrease in alcohol use severity over time. The findings support Prochaska et al.s transtheoretical model of the motivation for change. They suggest that the recognition of alcohol use problems comes along with learning adverse consequences of alcohol use and that increased determination to take actions is critical to the long-term behavioral changes in alcohol use.

Health resource utilization and clinical outcomes with risperidone therapy in patients with serious mental illness

This report is an analysis of our experience with risperidone therapy in a veteran population with severe, suboptimally responsive psychosis from a perspective of clinical response and health resource utilization. We conducted a computer search for all patients who received risperidone therapy at our facility from February 1994 until July 1, 1996. Risperidone at our facility is prescribed when psychiatric symptoms appear to be refractory or suboptimally responsive to conventional antipsychotic therapy. A control group of patients on conventional antipsychotic therapy were also selected via the electronic data base. One hundred twenty-nine patients received risperidone therapy at a mean dosage of 5.05+/-2.4 mg/d, for a mean duration of 247.4+/-223.5 days. The largest proportion of patients (48.1%) had marked improvement on risperidone therapy. There were 35 patients who received at least 1 year of risperidone therapy. These patients had a significant decrease in hospital length of stay (LOS) from 80.7 to 28.7 days (P = .003) on risperidone with no compensatory increase in outpatient visits. The group of patients who received conventional antipsychotic therapy during the study time period had a more modest mean reduction in LOS over a 2-year time period from 78.9 days during the initial identified year of conventional antipsychotic therapy to 56.4 days during the second identified year of conventional antipsychotic therapy (P = .2). However, when change in LOS for the entire group was compared, the difference in change in LOS between risperidone and conventional antipsychotic treated patients did not reach statistical significance (P = .2). This preliminary study concurs with other reports that risperidone therapy may be effective in severely mentally ill patients and may be associated with significant reductions in health resource utilization. Comparison of resource utilization between patients receiving risperidone and conventional antipsychotic therapy is still unclear and should be explored in larger and prospective studies.

A Preliminary Analysis of Individuals With Serious Mental Illness and Comorbid Diabetes

OBJECTIVE To understand factors related to managing illness in older individuals with serious mental illness (SMI). METHODS Baseline data from 200 individuals with SMI and diabetes enrolled in a study were used to compare characteristics between older (age >55) vs. younger (age ≤55) individuals. RESULTS Older individuals had better diabetes control compared to younger individuals, those with major depressive disorder had diabetes for a longer duration, worse diabetic control, and more emergency department encounters. CONCLUSIONS Helping younger individuals with SMI learn to manage their mental and physical health early-on might minimize the negative and cumulative effect of diabetes.

Psychosocial Features of Clinically Relevant Patient Subgroups With Serious Mental Illness and Comorbid Diabetes.

OBJECTIVE Care for people with serious mental illness and diabetes is complicated by clinical heterogeneity. This cross-sectional analysis of 200 individuals with comorbid serious mental illness and diabetes explored differentiation between patient subgroups that were characterized on the basis of selected dimensions within a biopsychosocial framework. METHODS Relationships between self-efficacy, treatment expectation, social support, and depression were first assessed via bivariate Spearman correlations among 200 individuals participating in a randomized controlled trial who had diabetes along with major depression, bipolar disorder, or schizophrenia. Next, latent profile analyses were conducted to determine underlying subgroups on the basis of these variables. The resultant groups were compared on diabetes control, function, and symptoms. RESULTS Two subgroups emerged. One had more severe psychiatric symptoms, low scores on other psychosocial variables, and worse diabetes control. The other had low levels of psychiatric symptoms, better scores on other variables, and better diabetes control. CONCLUSIONS Symptom presentation and internal and external resources appeared to be related to diabetes control for people with comorbid diabetes and serious mental illness. Care approaches need to go beyond standard education and consider biopsychosocial variables.

Race analysis in an African American sample with serious mental illness and comorbid diabetes.

Objectives: Targeted Training in Illness Management (TTIM) focuses on enhancing care engagement for people living with serious mental illness and diabetes. This secondary analysis from a 60-week, randomized controlled trial of TTIM versus treatment as usual evaluated racial subgroup outcomes. Method: Demographics, clinical characteristics, and diabetes status were evaluated for those self-identifying as non-Hispanic White, African American, and Hispanic. Longitudinal response to TTIM was evaluated using a multiple domain risk index. Due to their small sample size; those identifying as Hispanic were excluded from this analysis. Results: Non-Hispanic White participants had greater baseline socioeconomic advantages. Baseline risk scores, glycosylated hemoglobin (HbA1c) values, and HbA1c differences over time were similar for African American and non-Hispanic White participants. Conclusions and Implications for Practice: African American participants living with serious mental illness and diabetes receiving TTIM did as well as non-Hispanic White participants. Inclusive approaches that feature peer support and are situated in safety-net health care settings need to be further investigated with respect to potentially impacting health disparities.