Sandrine Loubière

Validation of the Medication Adherence Rating Scale in homeless patients with schizophrenia: Results from the French Housing First experience

The Medication Adherence Rating Scale (MARS) is one of the most widely used measurements of adherence in schizophrenia (SZ), but there is no available data regarding its psychometric properties in homeless SZ patients (HSZ). The aim of this study was therefore to assess the psychometric properties of the MARS in a large multicenter sample of HSZ subjects. This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. Three hundred and fifty-three patients were included. The 3-factor structure of the MARS was confirmed using confirmatory factor analysis: RMSEA = 0.045, CFI = 0.98, TLI = 0.97 and WRMR = 0.76. The unidimensionality of each factor was supported by the satisfactory INFIT statistics. Item internal consistencies were all higher than 0.20 and the Kuder–Richardson were higher than to 0.6, except for factor 2, which was closed to 0.5. Significant associations with symptoms, functioning and quality of life showed satisfactory external validity. The acceptability was satisfactory with missing data lower than 5% for each dimension. The MARS is a short self-administered instrument with acceptable psychometric properties in homeless SZ patients that yields interesting information about medication adherence.

Cost-effectiveness of KRAS, EGFR and ALK testing for decision making in advanced nonsmall cell lung carcinoma: the French IFCT-PREDICT.amm study

ALK rearrangement and EGFR/KRAS mutations constitute the primary biomarkers tested to provide targeted or nontargeted therapies in advanced nonsmall cell lung cancer (NSCLC) patients. Our objective was to assess the cost-effectiveness of biomarker testing for NSCLC. Between 2013 and 2014, 843 treatment-naive patients were prospectively recruited at 19 French hospitals into a longitudinal observational cohort study. Two testing strategies were compared, i.e. with “at least one biomarker status known” and “at least KRAS status known”, in addition to “no biomarker testing” as the reference strategy. The Kaplan–Meier approach was employed to assess restricted mean survival time. Direct medical costs incurred by hospitals were estimated with regard to treatment, inpatient care and biomarker testing. Compared with “no biomarker testing”, the “at least one biomarker status known” strategy yielded an incremental cost-effectiveness ratio of EUR13 230 per life-year saved, which decreased to EUR7444 per life-year saved with the “at least KRAS status known” testing strategy. In sensitivity analyses, biomarker testing strategies were less costly and more effective in 41% of iterations. In summary, molecular testing prior to treatment initiation proves to be cost-effective in advanced NSCLC management and may assist decision makers in defining conditions for further implementation of these innovations in general practice. KRAS, EGFR and ALK molecular testing before treatment initiation proves to be cost-effective in advanced NSCLC http://ow.ly/Ld1Z30ia9qv

Bread and Shoulders: Reversing the Downward Spiral, a Qualitative Analyses of the Effects of a Housing First-Type Program in France

This paper is a qualitative analysis of the effects of accompagnement, a support framework, on recovery trajectories of people with long-term homelessness and severe psychiatric disorders during 24 months in a Housing First-type program in France. A comprehensive methodology based on grounded theory was used to construct an interview guide, conduct multiple interviews with 35 Housing First participants sampled for heterogeneity, and produce memos on their trajectories before and after entering the program based on interview information. Thematic analysis of a representative subsample (n = 13) of memos identified 12 objective factors and 6 subjective factors key to the recovery process. An in-depth re-analysis of the memos generated four recovery themes: (1) the need for secure space favorable to self-reflexivity; (2) a “honeymoon” effect; (3) the importance of even weak social ties; (4) support from and hope among peers. Three challenges to recovery were identified: (1) finding a balance between protection and risk; (2) breaking downward spirals; (3) bifurcating the trajectory. This study provides new insight into the recovery process, understood as a non-linear transformation of an experience—the relationship between objective life conditions and subjective perception of those conditions—which reinforces protective support over risk elements.

Validity of a common quality of life measurement in homeless individuals with bipolar disorder and schizophrenia

OBJECTIVE To provide new evidence regarding the validity, reliability, sensitivity to change and acceptability of a schizophrenia (SCZ) quality of life measurement (S-QoL 18) in homeless people with bipolar disorder (BPD). METHODS This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. In addition to the S-QoL 18, data on sociodemographic information, disease severity using the Modified Colorado Symptom Index (MCSI), recovery using the Recovery Assessment Scale (RAS) and QoL using the Short-Form Health Survey (SF-36) were collected. The S-QoL 18 was tested for construct validity, reliability, external validity, sensitivity to change and acceptability. RESULTS In total, 216 homeless patients with BPD participated in this study. The eight-factor structure of the S-QoL 18 was confirmed by confirmatory factor analysis (RMSEA=0.058, CFI=0.98, TLI=0.966). The scalability was satisfactory, with INFIT statistics within an acceptable range (from 0.77 to 1.20). The internal consistency (from 0.43 to 0.76) and reliability coefficients (Cronbachs alpha from 0.65 to 0.86) were satisfactory for all dimensions. The external validity testing revealed that the S-QoL 18 dimension scores were significantly correlated with the MCSI, the RAS and the SF-36 scores. The percentage of missing data for the dimensions (<15%) and sensitivity to change were satisfactory. CONCLUSIONS These results demonstrate adequate acceptability and psychometric properties of the S-QoL 18 among homeless patients with BPD. The S-QoL 18 can be a common instrument for measuring QoL in homeless people with SCZ and BD.

The need to improve detection and treatment of physical pain of homeless people with schizophrenia and bipolar disorders. Results from the French Housing First Study

Objective The aim of this study was to investigate the prevalence and associated factors of physical pain in a large multicenter sample of Homeless Schizophrenia and Bipolar (HSB) patients. Methods This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Pain was measured by EQ5D‐3 L questionnaire with no specified period or location. In addition, sociodemographic information, duration of homelessness, illness severity using the Modified Colorado Symptom Index (MCSI) and drug information were collected. Results Overall, 655 HSB patients, mean age 38.8 years and 82.6% men were included, 448 (68.9%) were diagnosed with schizophrenia and 202 (31.1%) with bipolar disorder. More than half patients (N = 337, 51.5%) reported moderate to extreme physical pain while only 2.7% were administered analgesic drugs. In the multivariate analysis, self‐reported moderate to extreme physical pain was associated with antidepressant consumption (adjusted odd ratio aOR = 2.56[1.25;5.26], p = .01), female gender (aOR = 1.72[1.03;2.86], p = .04), bipolar disorders (vs. schizophrenia) (aOR = 1.81[1.19;2.77], p = .006), older age (aOR = 1.03 [1.01;1.05], p = .01), with higher MCSI psychotic score (a0R = 1.04[1.01;1.06], p = .002), independently of the number of days in the street during the last 180 days, MCSI depression score, alcohol and substance use disorders, psychotropic drugs and analgesic treatments. No association with education level, antipsychotics, mood stabilizers, anxiolytic, hypnotic or medication adherence was found (all p > .05). Conclusion Physical pain was highly reported in homeless patients with severe mental illness with insufficient care. Physical pain should be systematically explored and treated in this population. Bipolar disorders, antidepressant consumption and female gender may be targeted in priority. Age and psychotic symptomatology were found to influence self‐reported pain in a marginal way. Highlightsmore than half homeless subjects with severe mental illness reported moderate to extreme physical painhowever only 2.7% were administered analgesic drugsphysical pain was associated with antidepressant consumption, female gender, bipolar disorders, higher psychotic symptomatologythese results were independent of homelessness duration, depression, addictions and treatmentspain is underdiagnosed and undertreated in homeless subjects with severe mental illness

Prescription of potentially inappropriate psychotropic drugs in homeless people with schizophrenia and bipolar disorders. Results from the French Housing First (FHF) program

Background: Guidelines have been edited for the treatment of schizophrenia (SZ) and bipolar disorders (BD). Background regimen is currently recommended for both illnesses (antipsychotic drug for SZ and mood stabilizer for BD). The recommendations are less clear for major depression in these disorders. Long‐term anxiolytic and hypnotic prescriptions may have potential side effects and should be withdrawn as soon as possible. Objective: The aim of this study was to investigate the prevalence and associated factors of Potentially Inappropriate Psychotropic drugs (PIP) in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) patients. Methods: This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. PIP was defined by at least one item among: (i) absence of background regimen (antipsychotic for SZ or mood stabilizer for BD), (ii) absence of antidepressant for major depressive disorder and (iii) daily long‐term anxiolytic or (iv) hypnotic prescription. Results: Overall, 703 HSB patients, mean aged 38years and 82.9% men were included, 487 SZ (69.3%) and 216 BD (30.7%). 619 (88.4%) of the patients reported at least one PIP. 386 (54.9%) patients had an inappropriate background regimen prescription (209(43.4%) of SZ had no antipsychotic prescription and 177(81.9%) of BD no mood stabilizer), 336 (48%) had an inappropriate antidepressant prescription (with no significant difference between SZ and BD), 326 (46.4%) had an inappropriate prescription of anxiolytics and 107 (15.2%) had an inappropriate prescription of hypnotics. 388(55%) of the subjects were diagnosed with major depression but only 52(13%) of them were administered antidepressants. In multivariate analysis, PIP was associated with bipolar disorder diagnosis (aOR=4.67 [1.84–11.89], p=0.001), current major depressive disorder (aOR=27.72 [9.53–80.69], p<0.0001), lower rate of willingness to ask for help (aOR=0.98[0.96–0.99], p=0.001). Potentially inappropriate background regimen prescription was associated with bipolar disorder diagnosis (aOR=6.35 [3.89–10.36], p<0.0001), lower willingness to ask for help (aOR=0.99[0.98–0.99], p=0.01) and lack of lifetime history of psychiatric care (aOR=0.30[0.12–0.78], p=0.01). Inappropriate antidepressant prescription was associated with antisocial personality disorder (aOR=1.58 [1.01–2.48], p=0.04) and current substance use disorder (aOR=2.18[1.48–3.20], p<0.0001). Conclusion: The present findings suggest that almost 9 on 10 HSB subjects may receive a PIP including inappropriate prescriptions or absence of appropriate prescription. Bipolar disorder and/or major depression should be targeted in priority and treated with mood stabilizers and/or antidepressants in this population, while anxiolytics and hypnotics should be withdrawn as much as possible. Major depression should be particularly explored in subjects with comorbid antisocial personality disorder and substance use disorder. The psychiatric care has been associated with better appropriate psychotropic prescriptions and should be reinforced in this population. HIGHLIGHTSIn 703 homeless patients with schizophrenia (69.3%) or bipolar disorders (30.7%).619 (88.4%) of the patients reported at least one potentially inappropriate prescription (PIP).PIP was associated with bipolar disorder diagnosis, current major depressive disorder, lower willingness to ask for help.386 (54.9%) patients had an inappropriate prescription of antipsychotic (43.4%) or mood stabilizer (81.9%).336 (48%) had no antidepressant prescription despite current major depressive disorder.Inappropriate antidepressant prescription was associated with antisocial personality disorder and current substance use disorder.46.4% had an inappropriate prescription of anxiolytics and 15.2% of hypnotics.55% were diagnosed with major depression but only 13% of them were administered antidepressants.

Victimization and posttraumatic stress disorder in homeless women with mental illness are associated with depression, suicide, and quality of life

Objective This study aimed to determine the following: 1) the proportion of women in the homeless population with schizophrenia (SZ) or bipolar disorder (BD), in addition to the trajectory of their homelessness (ie, homelessness history, number of nights spent without home during the 180 past nights) and the characteristics of their illnesses compared to men (ie, illness severity, suicide risk, physical health status, and quality of life [QoL]); 2) whether these women were victimized more frequently than similarly situated men; 3) the impact of victimization on these women in terms of illness severity, suicide risk, physical health status, and QoL; and lastly 4) the differences and overlap of homeless women with SZ and BD. Methods This study employed data at baseline from a multicenter randomized controlled trial conducted in the following four large French cities: Lille, Marseille, Paris, and Toulouse. Mobile mental health outreach teams recruited SZ/BD homeless patients in the street, emergency shelters, hospitals, and jails from August 2011 to April 2014. Evaluations were performed during face-to-face interviews by psychiatrists and research assistants in the offices of mobile mental health outreach teams that were located in the downtown area of each city. The quantitative data were analyzed using descriptive analyses, chi-square and Student’s t-tests, generalized estimating equation regression models, and path analysis. Results A total of 703 patients were included in this study. The proportion of women in the SZ/BD homeless population was 123/703 (17.5%). In this population, women were more likely than men to declare that they were subjected to physical or sexual assault during the past 6 months, that they had been diagnosed with posttraumatic stress disorder (PTSD), and that they had experienced more severe depressive symptoms. Moreover, these women presented a higher suicide risk, worse physical health status, and lower QoL than similarly situated men. Homeless women with BD were more vulnerable than women with SZ. A path analysis revealed that PTSD and violent victimization might explain the higher levels of depression and suicide risk and the lower levels of physical health status and QoL in homeless women. Conclusion SZ/BD homeless women experience more PTSD and victimization than men, which are both associated with poor clinical outcomes. These results confirm the vulnerability of homeless women in this high need population and should be considered by public health policy.

Cost-effectiveness of biomarker testing for treatment choices in advanced non-small cell lung carcinoma: impact of diagnostic strategies and their turnaround times

We would like to thank A. Uguen for his correspondence with comments on our article [1]. In this prospective cohort study, the maximum cost for the diagnosis of advanced non-small cell lung cancer (NSCLC) was estimated to be 620 EUR, including EGFR/KRAS/ALK testing. In 52% of the patients in the “at least one biomarker status known”, the diagnostic strategy included EGFR/KRAS and ALK testing simultaneously, incurring a mean cost around 550 EUR. In 32% of the “at least one biomarker status known” group, the diagnostic strategy consisted first of a molecular analysis for KRAS with simultaneous immunohistochemistry (IHC) ALK testing, and second a targeted analysis for EGFR, followed by an additional validation by fluorescence in situ hybridisation assay for ALK IHC positive cases, for example at the time of second-line treatment initiation. For those patients, the total cost of the diagnostic strategy was estimated to be 616 EUR. All costs were based on reimbursed prices provided by the French Ministry of Health. Costs and turnaround-time impact of biomarker testing for treatment choices in advanced NSCLC in the NGS era http://ow.ly/16BV30k8Soz