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Zeina N Chemali,1,2 Christina PC Borba,1,2 Tanya E Henderson,3 Markos Tesfaye41Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA; 3International and Human Rights Law Consultants, Cambridge, MA, USA; 4Department of Psychiatry, College of Public Health and Medical Sciences, Jimma University, Jimma, EthiopiaAbstract: This paper presents the delivery of mental health care to a sample of women living in Jimma, rural Ethiopia, and their access to mental health services. A total of 226 psychiatric charts were reviewed for women seen at Jimma University Specialized Hospital. The mental health charts included documentation ranging from one paragraph to a full note. No psychiatric chart recorded medication status, detailed substance abuse history, or a history of violence. Rendering appropriate mental health care for women requires concerted efforts by multiple stake holders. Using our results, we advance concrete and practical suggestions for improving women's mental health in rural Ethiopia. We point out that the health care system needs to be responsive, allowing for change starting with gender rights, so that rural women have access to basic mental health services.Keywords: global mental health, low income country, Africa, gender differences

Background: A better understanding of attitudes and beliefs held by traditional healers and utilizers of traditional medicine concerning mental health conditions in Liberia is important as Liberia seeks to improve its delivery of mental healthcare in the context of scarce resources and recovery from civil war., Methods: A qualitative research design was used to collect data from 24 Liberian traditional healers, and 11 utilizers of Liberian traditional medicine. Participants were queried about mental health problems in Liberia, treatments, and attitudes towards modern healthcare. Qualitative data were probed and aggregated using content analysis., Results: Mental health problems described by study participants included: Open Mole, African Science, Epilepsy, Depression and Mental Illness (trauma/substance use). Mental health problems were often associated with socioeconomic distress, and participants described their attitudes and beliefs concerning mental healthcare, traditional medicine, and modern healthcare., Conclusion: Traditional medicine is an important part of mental healthcare in Africa. Mental illness, social factors, and healthcare access were important problems in Liberia. Mental health problems blended local cultural beliefs with Westernized nosology and social factors. Traditional healer's attitudes towards Western medicine reflected ambivalence. There is a desire for collaboration with 'modern' health care providers, but this will require reciprocal trust-building., (© 2021 Pullen SJ et al.)

Background: Given the increasing incidence of neonatal opioid withdrawal syndrome (NOWS), medical student training on substance use disorders (SUDs) and opioid use disorder (OUD) in pregnancy must be augmented. Through the Cuddling Assists in Lowering Maternal and Infant Stress (CALM) service-learning program, medical students attend SUD-related didactics and provide monthly cuddling services to infants with NOWS. Objective: This study examines the impact of CALM on medical students' attitudes toward individuals with SUDs and self-reported comfort with clinical skills related to caring for this population. Methods: Self-reported pre- and post-survey data was collected at the beginning and end of an academic year from the intervention group, CALM cuddlers, and the control group, non-cuddlers for 2 years. Mean total survey scores and individual survey questions using a 3-point Likert scale were compared before and after 1 year of participation for cuddlers and for non-cuddlers using paired t-tests and two sample t-tests. Results: The mean total score increased for cuddlers after participation in the intervention (MD 0.13, SD 0.26, p  = 0.03). Mean scores for the comfort-related subset of questions also increased significantly for cuddlers after participation in the intervention (MD 0.22, SD 0.41, p  = 0.01). Cuddlers felt more comfortable discussing substance use with appropriate language (72.0% vs 51.5%, p  = 0.03), talking with patients about substance use (72.0% vs 36.0%, p  = 0.01), and asking about substance use or recovery (80.0% vs 48.0%, p  = 0.01). Conclusion: OUD- and NOWS-related service-learning positively impacts student attitudes and self-reported comfort with skills related to caring for individuals with SUDs, such as communicating about substance use.

Perinatal depression/anxiety is considered the most underdiagnosed pregnancy complication in the US and is associated with poor maternal and fetal outcomes. However, despite its prevalence, most women who present with depressive symptoms are not screened and do not receive adequate treatment. We examined the clinical co-diagnosis of depression and/or anxiety among maternal and non-maternal hospitalizations among females aged 14-49 from the Nationwide Inpatient Sample (NIS) between 2004 and 2013 (n = 83,472,775). Meta-regression was used to determine annual change and presence of temporal trends. Survey logistic regression was used to examine the association with sociodemographic factors. Rates of diagnosis of depression and/or anxiety disorders demonstrated a temporal increase from 2004-2013, and this increase was mainly driven by non-maternal hospitalizations compared to maternal. Furthermore, non-maternal hospitalizations demonstrated a greater prevalence of depression and/or anxiety diagnoses compared to maternal hospitalizations over the same time period (21•7% versus 2•8%). Among all female hospitalizations, whites were roughly twice as likely as minorities to have a diagnosis of depression and/or anxiety. These results add to the evidence suggestive of the underdiagnosed depression/anxiety present among women of reproductive age, particularly pregnant women and minorities, and underscore the critical role of obstetricians in treating both physical and mental health., (Copyright © 2018. Published by Elsevier B.V.)

Background: Data on the use of seclusion for psychiatric inpatients in sub-Saharan Africa are extremely limited. Though seclusion is sometimes necessary for patients that pose a threat to themselves or others, adverse physical and psychological sequelae from the experience are increasingly being recognized, leading to efforts to reduce its use. The purpose of this study was to calculate the frequency of seclusion in patients hospitalized in an inpatient psychiatric unit in Lilongwe, Malawi, and to identify factors associated with its use., Methods: Records of 419 psychiatric inpatients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi, from January 1, 2011 to December 31, 2011, were reviewed. Multivariate logistic regression analysis was employed to identify factors associated with the use of seclusion., Results: Seclusion was used for 30.3% (127/419) of patients during the study period. Male patients had increased odds of being secluded (aOR: 2.22, p=0.02). Assaulting other patients on the unit (aOR 7.92, p<0.01) and presenting to the unit in mechanical restraints (aOR 2.33, p<0.01) were also associated with seclusion. There was no association between seclusion and age; diagnosis of alcohol use disorder, marijuana use disorder, or schizophrenia; involuntary admission; presence of extra pyramidal side effects; presence of hallucinations; suicidality; or commission of violent acts prior to admission., Conclusions: Documentation about the rationale for the use of seclusion on the unit was minimal. Improved record keeping requirements will be essential to future efforts to study seclusion and reduce its use. Development of strategies to address patient violence on the unit could decrease the use of seclusion for aggressive patients. Patients arriving to the unit in restraints would benefit from increased efforts by staff to apply behavioural interventions or administer medications, in order to deescalate these individuals and limit the use of seclusion in their treatment.

Depression and anxiety are common among patients who have a major cardiovascular event. However, despite their frequency, there is a lack of evidence regarding the relationship between depression and/or anxiety and receiving revascularization in ST-elevation myocardial infarction (STEMI) hospitalizations. Using data from the Nationwide Inpatient Sample (NIS) from the years 2004 to 2013, we assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations. Our central finding is that, paradoxically, the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. We further discovered that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. In conclusion, these results are suggestive of the potentially underdiagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole. To our knowledge, this is the first study to document and examine the "depression paradox" among a population of cardiac patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

This paper explores the potential benefits of the use of mobile health (mHealth) apps in obstetrician-gynecologist (OB-GYN)-embedded psychiatric clinics in the United States. First, we highlight the increasing trend of integrating mental health care within the OB-GYN context. Second, we provide examples of successful uses of mHealth in the global health context and highlight the dearth of available research in the United States. Finally, we provide a summary of the shortcomings of currently available apps and describe the upcoming trial of a novel app currently underway at the Mother-Child Wellness Clinical and Research Center at Boston Medical Center., (©Aydan Mehralizade, Shayna Schor, Chad M Coleman, Claire E Oppenheim, Christy A Denckla, Christina PC Borba, David C Henderson, James Wolff, Sarah Crane, Pamela Nettles-Gomez, Avik Pal, Snezana Milanovic. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 06.10.2017.)

Objective: As part of a larger implementation trial for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in a community health center, we used formative evaluation to assess relations between iterative cultural adaption (for Spanish-speaking clients) and implementation outcomes (appropriateness and acceptability) for CPT., Method: Qualitative data for the current study were gathered through multiple sources (providers: N = 6; clients: N = 22), including CPT therapy sessions, provider fieldnotes, weekly consultation team meetings, and researcher fieldnotes. Findings from conventional and directed content analysis of the data informed refinements to the CPT manual., Results: Data-driven refinements included adaptations related to cultural context (i.e., language, regional variation in wording), urban context (e.g., crime/violence), and literacy level. Qualitative findings suggest improved appropriateness and acceptability of CPT for Spanish-speaking clients., Conclusion: Our study reinforces the need for dual application of cultural adaptation and implementation science to address the PTSD treatment needs of Spanish-speaking clients., (© 2016 Wiley Periodicals, Inc.)

Child abuse is a global problem, and parents with histories of childhood abuse are at increased risk of abusing their offspring. The objective of this systematic review is to provide a clear overview of the existing literature of randomized controlled trials evaluating the effectiveness of interventions to prevent child abuse. PubMed, PsychINFO, Web of Science, Sociological Abstracts, and CINAHL were systematically searched and expanded by hand search. This review includes all randomized controlled trials (RCTs) of interventions designed to prevent abuse among mothers identified as high-risk. Of the eight studies identified, only three found statistically significant reductions in abuse by any measure, and only two found reductions in incidents reported to child protective services. While much has been written about child abuse in high-risk families, few RCTs have been performed. Only home visitation has a significant evidence base for reducing child abuse, and the findings vary considerably. Also, data from low- and middle-income countries are limited., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.

Background: In 2008, 5 years after the Liberian civil war ended, there were an estimated 340,000 orphans in Liberia, 18 % of the total child population of the country. Given that children make up half the population and that these children experienced significant trauma and loss both through direct exposure to the war and then to the Ebola epidemic, and indirectly as a result of the trauma experienced by their parents, the recovery of these children is essential to the recovery of the nation as a whole. The goal of this research was to identify factors contributing to resilience among youth in post-conflict Liberia. Resilience was defined as evidence of adaptive functioning and psychological health., Methods: Seventy-five young people (age 13-18) in the capital city of Monrovia, Liberia were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically., Results: Forty-six of the participants were attending school, and 29 were not enrolled in school. Youth enrolled in school demonstrated greater adaptive functioning. This was particularly true for boys in any school setting and girls attending private school. Youth not attending school were more likely to have lost family members or become estranged from them, and many were also engaging in substance use. Emotion regulation, cognitive flexibility, agency, social intelligence and, in some cases, meaning-making were found in participants who showed resilient outcomes., Conclusions: Caregiver relationships mediate the development of psychological capacities that impact resilience. These findings suggest that youth who have lost a caregiver, many of whom are not attending school, are experiencing a significant ongoing burden in terms of their daily functioning and psychological health in the post-war period and should be the focus of further study and intervention targeting substance use and community reintegration. Trial registration Partners Healthcare IRB Protocol# 2012P000367.

The effect that attending a 1-day workshop on Good Psychiatric Management (GPM) had on attitudes about borderline personality disorder (BPD) was assessed among 297 clinicians. Change was recorded by comparing before and after scores on a 9-item survey previously developed to assess the effects of workshops on Systems Training for Emotional Predictability and Problem Solving (STEPPS). Participants reported decreased inclination to avoid borderline patients, dislike of borderline patients, and belief that BPD's prognosis is hopeless, as well as increased feeling of competence, belief that borderline patients have low self-esteem, feeling of being able to make a positive difference, and belief that effective psychotherapies exist. Less clinical experience was related to an increased feeling of competence and belief that borderline patients have low self-esteem. These findings were compared to those from the STEPPS workshop. This assessment demonstrates GPM's potential for training clinicians to meet population-wide needs related to borderline personality disorder.

This study aims to elucidate relations between provider perceptions of aspects of the consolidated framework for implementation research (Damschroder et al., 2009) and provider attitudes toward the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semistructured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for cognitive processing therapy for posttraumatic stress disorder (Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes toward EBTs. Provider-identified client-level factors include the following: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

This study sought to clarify the contribution of posttraumatic stress disorder (PTSD) to interpersonal and occupational functioning in people with schizophrenia. Self-report questionnaires and semistructured interviews were used to evaluate PTSD and brain injury, positive symptoms, depression, substance abuse, occupational and social functioning, and intelligence. Multiple regressions assessed the relationship between predictors and functional impairment. Posttraumatic stress disorder symptoms were present in 76% of participants, with 12% of participants meeting diagnostic criteria for PTSD. Participants with PTSD had higher rates of depression and more severe positive symptoms. Results of multiple regressions indicated that PTSD symptoms were the only significant predictor of patient-rated interpersonal and occupational functioning. Posttraumatic stress disorder symptoms were not associated with interviewer-rated interpersonal or occupational functioning or employment. While more research is needed, screening and treatment for exposure to traumatic events and PTSD symptoms might be indicated for individuals with schizophrenia. Availability of PTSD assessment and evidence-based treatments for people with schizophrenia is a crucial and often unmet health service need.

Objective: Non-Latino blacks experience a higher proportion of chronic illness and associated disabilities than non-Latino whites. Posttraumatic stress disorder (PTSD) is associated with a greater risk of chronic illness, although few studies have investigated whether the interaction of PTSD with racial disparities may lead to a greater risk of chronic illness among blacks with PTSD than among whites with PTSD., Methods: We evaluated data from the population-based National Survey of American Life and the National Comorbidity Survey Replication to investigate the association between race, lifetime PTSD and self-reported chronic illness. Weighted linear and Poisson regression models assessed differences in the magnitude of association between PTSD and chronic illness by race on both the additive and multiplicative scales., Results: The magnitude of the association between lifetime PTSD and diabetes was greater among blacks (RD 0.07, 95% CI 0.02, 0.11; RR 1.9, 95% CI 1.4, 2.5) than whites (RD 0.004, 95% CI -0.02, 0.03; RR 1.2, 95% CI 0.7, 1.9) on the additive (p=0.017) scale. The magnitude of the association between lifetime PTSD and heart disease was greater among blacks (RD 0.09, 95% CI 0.05, 0.13) than whites (RD 0.04, 95% CI 0.01, 0.07) on the additive scale at a level approaching significance (p=0.051)., Conclusion: A lifetime history of PTSD was associated with a significantly greater risk of diabetes among blacks as compared to whites. These findings suggest that continuous exposure to racial inequalities may be associated with a greater risk of PTSD-related health sequela., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Substance use is a significant and common problem among school-aged youths throughout Africa. Like other countries on this continent, the West-African nation of Liberia is recovering from civil war. A well-educated population of young people is critical to the recovery efforts and long-term success of Liberia. Substance use by school-aged youths has important public health consequences that could undermine Liberia's post-conflict recovery efforts. We wanted to better understand the culturally significant themes and subthemes related to substance use among youths attending public schools in Monrovia, Liberia., Methods: A qualitative research design was used to collect data from 72 students attending public school in Monrovia, Liberia. Nine focus groups of 6-8 students from three public schools were facilitated using a semi-structured format to guide discussions on substance use. Student narratives were translated and re-occurring themes and subthemes were coded and analyzed., Results: Four emergent themes described in this study were: Behaviors associated with substance useConsequences associated with individual useConsequences of substance use that affected the school milieuSchool-related factors that were protective from substance use.Subthemes associated with substance use included concealment of substances, intoxication and disruption of the classroom environment, expulsion from school, school drop-out, and school as protective against substance use., Conclusion: Liberian school-aged youths described important themes and subthemes associated with substance use occurring within the school milieu. These data have germane public health ramifications, and could help inform larger epidemiologic study methods and public health interventions for Liberia and countries with similar profiles.

Between 1989 and 2004, Liberia experienced a devastating civil war that resulted in widespread trauma with almost no mental health infrastructure to help citizens cope. In 2009, the Liberian Ministry of Health and Social Welfare collaborated with researchers from Massachusetts General Hospital to conduct a rapid needs assessment survey in Liberia with local key informants ( n = 171) to examine the impact of war and post-war events on emotional and behavioral problems of, functional limitations of, and appropriate treatment settings for Liberian youth aged 5-22. War exposure and post-conflict sexual violence, poverty, infectious disease and parental death negatively impacted youth mental health. Key informants perceived that youth displayed internalizing and externalizing symptoms and mental health-related functional impairment at home, school, work and in relationships. Medical clinics were identified as the most appropriate setting for mental health services. Youth in Liberia continue to endure the harsh social, economic and material conditions of everyday life in a protracted post-conflict state, and have significant mental health needs. Their observed functional impairment due to mental health issues further limited their access to protective factors such as education, employment and positive social relationships. Results from this study informed Liberia's first post-conflict mental health policy.

The present study aimed to describe associations between various types of mental health stigma and help-seeking behaviors among ethnically diverse clients with posttraumatic stress disorder (PTSD) served by an urban community health clinic. The present study draws qualitative data from a parent National Institute of Mental Health Study that aims to identify barriers and facilitators of implementing Cognitive Processing Therapy (CPT) for PTSD. A total of 24 participants from the initial phase of the trial were included in the present study. Mental health stigma emerged as one notable barrier to seeking mental health treatment, as participants described how experiences of environment-level stigma, internalized (self-)stigma and perceived (felt) stigma from their family, friends and previous healthcare providers influenced their decisions to seek care. Despite these barriers to help seeking, many clients also reported that positive interactions with informal and formal support systems, and encouragement from study therapists, helped to combat mental health stigma and facilitate decisions to participate in an implementation trial for CPT. Findings suggest that providers in community health settings may need to attend directly to stigma at the initiation of mental health treatment.

Objectives: Childhood abuse is associated with increased risks of adult psychiatric disorders and physical health conditions. Mounting evidence documents associations of childhood abuse with sleep disturbances in adulthood. However, to date, no study has evaluated associations of childhood abuse and sleep disturbances among pregnant women., Methods: This cross-sectional study included 634 pregnant Peruvian women. To collect information regarding socio-demographic characteristics, history of childhood abuse, and complaints of sleep disturbances, face-to-face interviews were conducted with women in early pregnancy. Ford Insomnia Response to Stress Test (FIRST-S) and the Pittsburgh Sleep Quality Index (PSQI-S), translated from English to Spanish, were used to assess stress-related sleep disturbance and sleep quality, respectively. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CIs)., Results: Women who experienced any childhood abuse had a 1.65-fold increased odds of stress-related sleep disturbance (aOR = 1.65; 95% CI: 1.15-2.38) and 2.11-fold increased odds of poor sleep quality during early pregnancy (aOR = 2.11; 95% CI: 1.35-3.30) as compared with women who reported no abuse. Women who reported both physical and sexual abuse during childhood were more than twice as likely to suffer from stress-related sleep disturbance (aOR = 2.26; 95% CI: 1.44-3.53) and poor sleep quality (aOR = 2.43; 95% CI: 1.45-4.09) in comparison to women who reported no childhood abuse., Conclusions: A history of childhood abuse is associated with increased odds of stress-related sleep disturbance and poor sleep quality during pregnancy. These findings, if replicated, should be used to inform the development of trauma-informed care for such sleep disturbances induced by childhood trauma., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: To examine the independent and joint relationships of poor subjective sleep quality and antepartum depression with suicidal ideation among pregnant women., Methods: A cross-sectional study was conducted among 641 pregnant women attending prenatal care clinics in Lima, Peru. Antepartum depression and suicidal ideation were assessed using the Patient Health Questionnaire-9 scale. Antepartum subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Logistic regression procedures were performed to estimate odds ratios (aOR) and 95% confidence intervals (95% CI) adjusted for confounders., Results: Overall, the prevalence of suicidal ideation in this cohort was 16.8% and poor subjective sleep quality was more common among women endorsing suicidal ideation as compared to their counterparts who did not (47.2% vs. 24.8%, P<.001). After adjustment for confounders including maternal depression, poor subjective sleep quality (defined using the recommended criteria of PSQI global score of >5 vs. ≤5) was associated with a 1.7-fold increased odds of suicidal ideation (aOR=1.67; 95% CI 1.02-2.71). When assessed as a continuous variable, each 1-unit increase in the global PSQI score resulted in an 18% increase in odds for suicidal ideation, even after adjusting for depression (aOR=1.18; 95% CI 1.08-1.28). Women with both poor subjective sleep quality and depression had a 3.5-fold increased odds of suicidal ideation (aOR=3.48; 95% CI 1.96-6.18) as compared with those who had neither risk factor., Conclusion: Poor subjective sleep quality was associated with increased odds of suicidal ideation. Replication of these findings may promote investments in studies designed to examine the efficacy of sleep-focused interventions to treat pregnant women with sleep disorders and suicidal ideation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To determine whether physician's attitudes toward patients with comorbid mental illness affect management of a chronic disease., Data Source: A total of 256 primary care physicians interviewed in 2010., Study Design: This randomized factorial experiment entailed physicians observing video vignettes of patient-actors with poorly controlled diabetes. Patients were balanced across age, gender, race, and comorbidity (schizophrenia with bizarre or normal affect, depression, eczema)., Data Collection: Physicians completed structured and semistructured interviews plus chart notes about clinical management and attitudes., Principal Findings: Physicians reported more negative attitudes for patients with schizophrenia with bizarre affect (SBA). There were few differences in clinical decisions measured quantitatively or in charting, but qualitative data revealed less trust of patients with SBA as reporters, with more reliance on sources other than engaging the patient in care. Physicians often alerted colleagues about SBA, thereby shaping expectations before interactions occurred., Conclusions: Results are consistent with common stereotypes about people with serious mental illness. Vignettes did not include intentional indication of unreliable reporting or danger. Reducing health care disparities requires attention to subtle aspects of managing patients--particularly those with atypical affect--as seemingly slight differences could engender disparate patient experiences over time., (© Health Research and Educational Trust.)

Our program attempted to improve attitudes and confidence of Peruvian primary care physicians (PCPs) providing mental health care. The training program underwent an evaluation to determine impact of sustained confidence in performing medical and psychiatric procedures, and application of learned skills. Fifty-two Peruvian primary care practitioners were trained at the Harvard Program in Refugee Trauma (HPRT) over a two-week period. There was significant improvement in PCPs' confidence levels of performing psychiatric procedures (counseling, prescribing medications, psychiatric diagnosis, assessing the risk for violence, and treating trauma victims) when comparing baseline and post-two-week to one year follow-up. When comparing post-two-week and one-year follow-up quantitative measures, confidences levels went slightly down. This may be an implication that the frequency of trainings and supervisions are needed more frequently. In contrast, qualitative responses from the one-year follow-up revealed increase in victims of violence clinical care, advocacy, awareness, education, training, policy changes, accessibility of care, and sustainment of diagnostic tools. This study supports the feasibility of training PCP's in a culturally effective manner with sustainability over time.

Objective: The aim of this study was to investigate the role of pravastatin, as an adjunctive therapy, on inflammatory markers, lipid and glucose metabolism, psychopathology, and cognition in subjects with schizophrenia and schizoaffective disorder., Methods: Schizophrenia or schizoaffective subjects (N=60) were randomized to receive either a 12-week supply of pravastatin 40 mg/day or placebo treatment. Anthropometric measures, lipids and glucose metabolism, inflammatory markers, psychopathology and cognitive performance were assessed at baseline, 6 weeks and 12 weeks., Results: Pravastatin use was associated with a significant decrease in total cholesterol, low density lipoprotein (LDL) cholesterol and LDL particle number levels, but was not associated with any significant changes in cognition or psychopathology in the participants, except a significant decrease in the Positive and Negative Syndrome Scale (PANSS) positive symptom score from baseline to week 6. However, this decrease failed to remain significant at 12 weeks. Interestingly, triglycerides, LDL-cholesterol, total cholesterol, LDL particle number, small LDL particle number, large very low density lipoprotein (VLDL) particle number and C-reactive protein (CRP) followed a similar pattern at 6 and 12 weeks as psychopathology., Conclusions: These results suggest that a randomized trial with a larger sample size and a higher dosage of pravastatin would be helpful in further evaluating the anti-inflammatory properties of pravastatin, its association with improvements in cognitive symptoms, and its potential to reduce positive and negative symptoms associated with schizophrenia or schizoaffective disorders., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: This study analyzes the relationship between informants' age and their assessment of mental health needs in postconflict society and examines if mental health needs assessment priorities differ depending upon whether or not the informant was exposed to the Liberian civil war., Methods: cross-sectional survey was conducted in March 2009 to obtain data on mental health needs of Liberian children, adolescents and young adults. A total of 171 individuals were interviewed. The data were analyzed using a two- way ANOVA., Results: Elder respondents expressed a preference for young adults to receive services in a church/mosque (F = 4.020, p < .05); for adolescents in volunteer programs (F = 3.987, p < .05) and for children in sports programs (F = 4.396, p < .05). Experiencing conflict did exert some influence on treatment setting preferences. Those who resided outside Liberia during the conflict cited a preference for traditional healers and medical clinics. However, this preference was for the children and young adult age categories. Those who experienced the civil war reported significantly higher preferences for adolescent services to be located in medical clinics, with traditional healers, and in churches/mosques., Conclusion: This study provides additional support for the premise that the utilization of psychiatric services needs to be viewed from the perspective of Liberians and that there are differences in preferences across groups. Our results suggest that service providers and policy makers take into account the age of the patient when deciding where to locate treatment settings for the population.

Objective: The study examined key informants' perceptions of the emotional impact of traumatic events, major problems, functional limitations and appropriate treatment settings for children, adolescents, and young adults in post-conflict Liberia., Method: This research is a based on cross-sectional survey conducted between March 30, 2009 and April 30, 2009 in Liberia with 171 local key Liberian informants. Analysis was conducted using mixed methods. The findings we will report were collected in the qualitative portion of the survey., Results: We found that while different interventions were preferred for different types of young people, some interventions were mentioned for all youth and by all age and gender groups of key informants. These included counseling, education, and skills training. Also frequently chosen were housing, community reintegration, recreation, and medical care. In general, key informants reported similar concerns regardless of their ages or genders. Notable exceptions to this were in interventions for youth who joined fighting forces. Men over 50 were the only ones to recommend apology and reparations. Similarly, in recommendations for criminals and violent youth, a number of men mentioned prison, whereas the women did not., Conclusion: Our findings suggest that the needs of post-conflict Liberian youth span a variety of domains, including physical, emotional, medical, psychological, and educational. These findings can be used to guide the development of treatment programs for these young people.

Previous studies have linked vitamin D deficiency to hypertension, dyslipidemia, diabetes mellitus, and cardiovascular disease. The aim of this study was to investigate the short-term effects of vitamin D₃ supplementation on weight and glucose and lipid metabolism in antipsychotic-treated patients. A total of 19 schizophrenic or schizoaffective patients (BMI>27 kg/m²) taking atypical antipsychotics were recruited and dispensed a 2000 IU daily dose of vitamin D₃. On comparing baseline with week 8 (study end) results, we found a statistically significant increase in vitamin D₃ and total vitamin D levels but no statistically significant changes in weight, glucose, or lipids measurements. Patients whose vitamin D₃ level at week 8 was 30 ng/ml or more achieved a significantly greater decrease in total cholesterol levels compared with those whose week 8 vitamin D₃ measurement was less than 30 ng/ml. These results suggest that a randomized trial with a longer follow-up period would be helpful in further evaluating the effects of vitamin D₃ on weight, lipid metabolism, and on components of metabolic syndrome in antipsychotic-treated patients.

Background: We present a retrospective study examining response to treatment with fibrates or statins in schizophrenia patients., Methods: We identified the patient population using the Research Patient Data Registry. Demographic data, total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and non-HDL cholesterol (non-HDL-C) levels were obtained before initiation of treatment with lipid-lowering medication (LLM) and after LLM treatment was initiated (N = 183)., Results: Treatment with LLMs resulted in a statistically significant decrease in total cholesterol, triglycerides, LDL-C, and non-HDL-C. An independent-samples t test comparing the statin treatment-alone group with the fibrate treatment-alone group showed a significant reduction in triglyceride levels from baseline to 1-year follow-up in the fibrate treatment-alone group., Conclusions: The results of this study indicate that schizophrenia patients respond to LLMs in a manner consistent with the general population. Future studies would benefit from a larger sample, as well as comparisons between more specific treatment groups, such as those defined by type of statin or fibrate, to observe differential effects on specific markers of dyslipidemia in this population.

Objective: This study examined the effects of adjunctive aripiprazole therapy on metabolism in clozapine-treated patients with schizophrenia., Method: In an 8-week randomized, double-blind, placebo-controlled study, subjects received either aripiprazole (15 mg/day) or placebo. At baseline and week 8, metabolic parameters were assessed by the frequently sampled intravenous glucose tolerance test, nuclear magnetic resonance spectroscopy and whole-body dual-energy X-ray absorptiometry (DXA)., Results: Thirty subjects completed the study (16 in the aripiprazole group and 14 in the placebo group). Glucose effectiveness measured by the frequently sampled intravenous glucose tolerance test improved significantly in the aripiprazole group (0.003 ± 0.006 vs. -0.005 ± 0.007/min, P = 0.010). The aripiprazole group showed significant reductions in both plasma low-density lipoprotein (LDL) levels (-15.1 ± 19.8 vs. 4.4 ± 22.5 mg/dl, P = 0.019) and LDL particle numbers (-376 ± 632 vs. -36 ± 301 nm, P = 0.035). Further, there was a significant reduction in the lean mass (-1125 ± 1620 vs. 607 ± 1578 g, P = 0.011) measured by whole-body DXA scan in the aripiprazole group. All values were expressed as mean ± standard deviation, aripiprazole vs. placebo., Conclusion: Adjunctive therapy with aripiprazole may have some metabolic benefits in clozapine-treated patients with schizophrenia., (© 2012 John Wiley & Sons A/S.)

Objective: This qualitative study investigates the barriers and facilitators to accessing and utilizing healthcare services among women with a serious mental illness (SMI)., Methods: A purposive sample of 30 poor, urban, predominantly African-American women with a diagnosis of an SMI was recruited. Interviews were audio-taped and transcribed verbatim. Data analysis was guided by a modified constant comparison approach., Results: The findings highlight a variety of nonmedical factors that serve as both barriers and facilitators to accessing and utilizing medical healthcare services, such as a trusting relationship with a mental health provider and a women's social network., Conclusion: Nonmedical factors and personal circumstances seem to be important factors influencing pathways to healthcare services among women with an SMI. Efforts to better engage and retain women with an SMI into healthcare will need to better acknowledge and incorporate the larger social context of the women's lives., (Copyright © 2012 Jacobs Institute of Women)

We suggest that the optimal approach to building capacity in global mental health care will require partnerships between professional resources in high-income countries and promising health-related institutions in low- and middle-income countries. The result of these partnerships will be sustainable academic relationships that can educate a new generation of in-country primary care physicians and, eventually, specialized health professionals. Research capabilities will be an essential educational component to inform policy and practice, and to ensure careful outcome measurements of training and of intervention, prevention, and promotion strategies. The goal of these academic centers of excellence will be to develop quality, in-country clinical and research professionals, and to build a productive environment for these professionals to advance their careers locally. In sum, this article discusses human capacity building in global mental health, provides recommendations for training, and offers examples of recent initiatives.

Objective: Few interventions have been successful to prevent or reverse the medical complications associated with antipsychotic agents in the schizophrenia population. In particular, no single agent can correct multiple metabolic abnormalities such as insulin resistance, hyperlipidemia, inflammation, obesity, and fat distribution. We now report a randomized placebo-controlled pilot study to examine the effects of ramelteon on obesity and metabolic disturbances among subjects with schizophrenia., Methods: A double-blind, placebo-controlled, 8-week pilot trial was conducted, adding ramelteon 8 mg/d to stable outpatients with schizophrenia. Vital signs and anthropometric measurements, including height, weight, waist circumference, and body fat were assessed, and laboratory assays were tracked to monitor changes in metabolic markers., Results: Twenty-five subjects were randomly assigned to treatment with study drug or placebo, and 20 subjects were included in the final analysis. Ramelteon did not improve anthropometric measurements, glucose metabolism, and inflammatory markers. There was, however, a significant decrease in total cholesterol and ratio of cholesterol to high-density lipoprotein in the ramelteon group. Although the standard anthropometric measures did not show significant change, the dual-energy x-ray absorptiometry scan showed a trend toward reduction in fat in the abdominal and trunk areas with a moderate effect size., Conclusions: Although ramelteon decreased cholesterol, treatment may have to be longer than 8 weeks and with a higher dose for maximal effect of ramelteon for body fat and lipid changes. Future studies are needed for patients with schizophrenia with a larger sample size to fully understand ramelteon's effects on abdominal adiposity and lipids.

Rationale: Sedation is a common side effect of clozapine treatment and may exacerbate metabolic consequences of poor diet and exercise habits that are common in patients with schizophrenia. Modafinil has been proposed as a treatment for clozapine-induced sedation and metabolic abnormalities., Objective: To estimate the effect sizes and person-to-person variation in anthropometric measures, glucose and lipid metabolism, and diet on modafinil treatment for future randomized control trials., Methods: A double-blind, placebo-controlled, flexible-dosed 8-week pilot trial was conducted, adding modafinil up to 300 mg/day to stabilized schizophrenia outpatients receiving clozapine. Blood pressure, weight, BMI, laboratory assays, and dietary intake were tracked to monitor changes in metabolic markers., Results: Thirty-five participants were randomly assigned to treatment with study drug or placebo and were included in the analysis. Modafinil did not improve blood pressure, weight, BMI, glucose or lipid metabolism compared to placebo. Modafinil was well tolerated and did not worsen psychosis., Conclusions: Results of this pilot trial do not support routine use of modafinil to counteract increased weight and metabolic diseases in patients taking clozapine. However, the effects of modafinil on weight and insulin regulation warrant further investigation with effect sizes of 0.4 to 0.6., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Purpose: Few studies have taken a holistic perspective to the lives of women with a serious mental illness (SMI). This qualitative study of women with an SMI describes and interprets women's experiences and provides a new understanding about the nature and needs of these women., Methods: A convenience sample of 30 poor, urban, predominantly African-American women with a diagnosis of an SMI was recruited from an ongoing National Institutes of Mental Health study. Data collection involved face-to-face, in-depth interviews. The interviews were audio-recorded and transcribed verbatim. Data analysis occurred concurrently with data collection using a modified constant comparative method., Results: The majority of the women self-identified as African American, single, having completed high school, and at the time of the interview were either unemployed or on disability. The most common SMI was major depression. A common topic in the women's reflections on their lives was that of social disadvantage both before being diagnosed as well as after to their diagnosis with an SMI. Salient themes of their stories included social isolation, experiencing loss, and having a lack of control over one's own life decisions., Conclusion: The findings from this study revealed varied experiences among these women as well as the complexity of their situation. The enhanced understanding of women's situation will allow mental health professionals to improve the quality of life for women with an SMI by taking a contextual approach to the treatment of their mental illness., (Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Background: High dietary saturated fat (SF) intake is strongly linked to metabolic disturbances. The goal of this study was to understand the relationship between clozapine and risperidone with glucose and lipid metabolism and dietary fat intake in patients with schizophrenia., Methods: Thirty-one clozapine-treated patients and 15 risperidone-treated patients were assessed using a 4-day dietary record, an IV glucose tolerance test, and lipid profiles., Results: Clozapine-treated patients consumed a significantly higher percentage of SF than did risperidone-treated patients (13.7% +/- 3.4% vs 10.6% +/- 3.0 % of total energy; P = .007). Compared with the risperidone group, the clozapine group also had a significantly higher percentage of total fat in their diet (36% +/- 6.7% vs 30.9% +/- 5.7% of total energy; P = .007). Similarly, the clozapine group had a significant impairment in insulin sensitivity index (SI), glucose effectiveness (SG), and disposition index (DI) compared with the risperidone group (P < .05). Pearson correlation analysis of both groups showed that dietary SF was significantly correlated with impairment in glucose homeostasis (SG: r = -0.43; P = .004; DI: r = -0.35; P = .02)., Conclusion: Abnormal glucose homeostasis in atypical clozapine-treated patients with schizophrenia may be associated with or aggravated by high dietary SF consumption.

Context: Living donation is studied with much less intensity among African Americans than among the general population. Examination of barriers to living donation can lead to effective strategies to educate dialysis patients and their families about this alternative., Objective: To explore the correlates of likelihood of becoming a living donor among community-recruited African American adults., Design/participants: Cross-sectional data were gathered via self-administered questionnaire from 425 African American adults, age 18 years and older, who were recruited from 9 churches in Atlanta., Main Outcome Measures: Self-reported likelihood of becoming a living donor to a close family member, an extended family member or friend, or a stranger., Results: More than three-quarters of participants were willing to act as living donors to a close family member or spouse and two-thirds to friends or extended family. For likelihood of donating to a friend or extended family member, only willingness to engage in deceased donation was significantly associated; to a stranger, both willingness to engage in deceased donation and attitudes toward donation were significantly associated. Knowledge of and personal experiences with donation and/or transplantation were not significantly associated with likelihood of any type of living donation., Conclusions: Findings indicate widespread support for living donation to a close family member or spouse. These findings have important implications for dialysis patients who must decide whether to approach friends and/or family about the possibility of serving as a living donor and emphasize the need for interventions to help facilitate this process.

Objective: The goal of this study was to evaluate which anthropometric measure (human body measurement) best predicts insulin resistance measured by the insulin sensitivity index (SI) and the homeostasis model of assessment of insulin resistance (HOMA-IR) in nondiabetic patients with schizophrenia treated with clozapine or olanzapine., Methods: We conducted a cross-sectional study of nondiabetic subjects with schizophrenia being treated with olanzapine or clozapine using a frequently sampled intravenous glucose tolerance test, nutritional assessment, and anthropometric measures, to assess the relationship between anthropometric measures and insulin resistance., Results: No difference was found between the groups treated with clozapine and olanzapine in age, gender, race, body mass index (BMI), waist circumference (WC), lipid levels, HOMA-IR, or SI. The disposition index (SI x the acute insulin response to glucose), which measures how the body compensates for insulin resistance to maintain a normal glucose level, was significantly lower in the group treated with clozapine than in the group treated with olanzapine (1067+/-1390 vs. 2521+/-2805; P=0.013), suggesting that the subjects treated with clozapine had a reduced compensatory response to IR compared with the subjects treated with olanzapine. In the clozapine group, both higher WC and BMI were significantly associated with elevated HOMA-IR and lower SI; however, WC was a stronger correlate of IR than BMI, as measured by SI (-0.50 vs. -0.40). In the olanzapine group, neither WC nor BMI was significantly associated with any measure of glucose metabolism., Conclusions: In this study, WC was the single best anthropometric surrogate for predicting IR in patients treated with clozapine but not olanzapine. The results suggest that WC may be a valuable screening tool for predicting IR in patients with schizophrenia being treated with clozapine who are at relatively higher risk of developing the metabolic syndrome, type 2 diabetes mellitus, and associated cardiovascular disease.

Objective: The primary purpose of this 8-week double-blind, placebo-controlled trial of rosiglitazone 4 mg/day was to examine its effect on insulin sensitivity index (SI) and glucose utilization (SG) in clozapine-treated subjects with schizophrenia with insulin resistance., Method: Eighteen subjects were randomized and accessed with a Frequently Sampled Intravenous Glucose Tolerance Test (FSIVGTT) at baseline and at week 8 to estimate SG and SI., Results: Controlling for the baseline, comparing the rosiglitazone group with placebo group, there was a non-significant improvement in SG (0.016 +/- 0.006-0.018 +/- 0.008, effect size = 0.23, P = 0.05) with a trend of improvement in SI in the rosiglitazone group (4.6 +/- 2.8-7.8 +/- 6.7, effect size = 0.18, P = 0.08). There was a significant reduction in small low-density lipoprotein cholesterol (LDL-C) particle number (987 +/- 443-694 +/- 415, effect size = 0.30, P = 0.04)., Conclusion: Rosiglitazone may have a role in addressing insulin resistance and lipid abnormalities associated with clozapine.

Objective: This study sought to examine the effect of ziprasidone on olanzapine or clozapine-associated medical morbidity such as insulin resistance, diabetes mellitus (DM) and impaired fasting glucose, obesity, and hyperlipidemia in patients with schizophrenia or schizoaffective disorder., Method: This was a 6-week, open label trial of ziprasidone 160 mg/day added to a stable dose of olanzapine or clozapine in 21 schizophrenia or schizoaffective patients with DM, impaired fasting glucose, or insulin resistance., Results: Ten olanzapine-treated subjects and 11 clozapine-treated subjects were enrolled in the study. There were no significant differences between the two groups at baseline for age, gender, education, ethnicity, BMI, cholesterol levels, or fasting glucose. At week 6, there were no significant changes in weight, BMI, cholesterol levels, or fasting glucose. There was no significant difference in psychotic, negative, or depressive symptoms. QTc significantly increased at week 2 but not at week 6., Conclusions: The addition of 160 mg/day of ziprasidone was well tolerated but did not produce significant improvement in fasting glucose, insulin resistance, hyperlipidemia or lead to weight loss in olanzapine- or clozapine-treated subjects with schizophrenia or schizoaffective disorder.

Olanzapine treatment has been associated with clinically meaningful weight increases, hypertriglyceridemia, insulin resistance, and diabetes mellitus. There are few options for olanzapine responders who fail other antipsychotic agents. Aripiprazole is a potent (high-affinity) partial agonist at D2 and 5-HT1A receptors and a potent antagonist at 5-HT2A receptor and is associated with less weight gain than olanzapine. We report the results of a 10-week placebo-controlled, double-blind crossover study that examined 15 mg/d aripiprazole's effects on weight, lipids, glucose metabolism, and psychopathology in overweight and obese schizophrenia and schizoaffective disorder subjects treated with a stable dose of olanzapine. During the 4 weeks of aripiprazole treatment, there were significant decreases in weight (P = 0.003) and body mass index (P = 0.004) compared with placebo. Total serum cholesterol (P = 0.208), high-density lipoprotein cholesterol (HDL-C; P = 0.99), HDL-2 (P = 0.08), HDL-3 (P = 0.495), and low-density lipoprotein cholesterol (P = 0.665) did not change significantly comparing aripiprazole treatment to placebo treatment. However, total serum triglycerides (P = 0.001), total very low-density lipoprotein cholesterol (VLDL-C; P = 0.01), and VLDL-1C and VLDL-2C (P = 0.012) decreased significantly during the aripiprazole treatment phase. The VLDL-3C tended lower during aripiprazole, but the decrease was not significant (P = 0.062). There was a decrease in C-reactive protein comparing aripiprazole treatment to placebo, although it did not reach significance (P = 0.087). The addition of aripiprazole to a stable dose of olanzapine was well tolerated and resulted in significant improvements on several outcome measures that predict risk for medical morbidity.

Background: Theory-based health behavior change programs are thought to be more effective than those that do not use theory. No previous reviews have assessed the extent to which theory is used (that is, operationalized and tested) in empirical research., Purpose: The purpose of this study was to describe theory use in recent health behavior literature and to assess the proportion of research that uses theory along a continuum from: informed by theory to applying, testing, or building theory., Methods: A sample of empirical research articles (n = 193) published in ten leading public health, medicine, and psychology journals from 2000 to 2005 was coded to determine whether and how theory was used., Results: Of health behavior articles in the sample, 35.7% mentioned theory. The most-often-used theories were The Transtheoretical Model, Social Cognitive Theory, and Health Belief Model. Most theory use (68.1%) involved research that was informed by theory; 18% applied theory; 3.6% tested theory; and 9.4% sought to build theory., Conclusions: About one third of published health behavior research uses theory and a small proportion of those studies rigorously apply theory. Patterns of theory use are similar to reports from the mid-1990s. Behavioral researchers should strive to use theory more thoroughly by applying, testing, and building theories in order to move the field forward.

The purpose of the present study was to assess posttraumatic stress disorder (PTSD), cognitive function, and quality of life in patients with schizophrenia who had a self-reported history of trauma exposure. Outpatients diagnosed with schizophrenia or schizoaffective disorder were referred to the study. Each patient was assessed with the Positive and Negative Syndrome Scale (PANSS), the Harvard Trauma Questionnaire (HTQ), a cognitive assessment battery, Heinrich's Quality of Life Scale (QLS), and the Behavior and Symptom Identification Scale (BASIS). Eighty-seven subjects who reported experiencing at least one traumatic event were included in the study. Fifteen of 87 (17%) met the DSM-IV criteria for PTSD. The PTSD group had significantly worse overall cognitive performance than the non-PTSD group, especially in the domains of attention, working memory and executive function. In addition, the PTSD group showed significantly worse self-rated quality of life as measured by the BASIS total score. The development of PTSD is associated with poor cognitive function and subjectively, but not objectively, rated low quality of life in patients with schizophrenia. Evaluating PTSD in patients with schizophrenia could have important implications from both clinical and research perspectives.

Objective: We conducted a retrospective epidemiologic study assessing the incidence of new-onset diabetes mellitus presenting as diabetic ketoacidosis in patients with schizophrenic disorders (ICD-9 295.0-295.9; referred to as "schizophrenia patients" hereafter) treated with atypical antipsychotic agents., Method: The identification of patients and the review of records were achieved by using an electronic database linking administrative and clinical laboratory data between January 1, 1995, and December 31, 2001. The main outcome measure was the incidence of diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome per 10,000 patient years in patients with new-onset or existing diabetes mellitus. We also determined the incidence of diabetic ketoacidosis associated with the use of atypical antipsychotics and calculated the mean hemoglobin A1c (HbA1c) level for all patients., Results: During the 7-year period, 18.4% of schizophrenia patients were diagnosed with diabetes mellitus, compared with 6.6% in the general hospital population (p < .001). After chart review, 23 schizophrenia patients were identified with diabetic ketoacidosis: 11 had diabetes presenting as diabetic ketoacidosis, 8 had diabetic ketoacidosis with known diabetes mellitus, 2 had new-onset diabetes mellitus-hyperosmolar hyperglycemic syndrome, and 2 had hyperosmolar hyperglycemic syndrome with known diabetes mellitus. The incidence of diabetes presenting as diabetic ketoacidosis in schizophrenia patients was more than 10-fold higher than that reported in the general population: 14.93 per 10,000 patient years in schizophrenia patients versus 1.4 per 10,000 patient years in the general population (p < .000001) and versus the 1.98 per 10,000 patient years in the general hospital population (p < .000001). The incidence of diabetic ketoacidosis for each of atypical antipsychotic drugs over the 7-year period was as follows: clozapine, 2.2%; olanzapine, 0.8%; and risperidone, 0.2% (no incidence with ziprasidone or quetiapine). Of the 11 patients with diabetes presenting as diabetic ketoacidosis, the mean HbA1c level at admission was 13.3% +/- 1.9% (10.4%-16.9%)., Conclusions: The incidence of diabetes mellitus presenting as diabetic ketoacidosis in schizophrenia patients is higher than in the general hospital population and differs across atypical antipsychotic agents. Elevated HgbA1c levels observed suggests that patients had undiagnosed diabetes mellitus for at least several weeks before the diabetic ketoacidosis episode.

Unlabelled: This study sought to examine the effectiveness of sibutramine, a weight loss agent, on clozapine-associated weight gain., Method: This was a 12-week double-blind, placebo controlled, randomized trial of sibutramine for weight loss in obese clozapine-treated schizophrenia or schizoaffective disorder subjects., Results: Ten patients were enrolled into the placebo group and 11 patients into the sibutramine group. There were no significant baseline differences between the two groups on age, gender, education, ethnicity, diagnosis, weight, body mass index (BMI), and blood pressure. At week 12, there were no significant differences in changes in weight, BMI, abdominal and waist circumferences, Hba1c, fasting glucose, or cholesterol levels., Conclusion: Sibutramine treatment did not show significant weight loss compared with placebo in clozapine-treated patients with schizophrenia or schizoaffective disorder. Further research with a larger sample size and longer follow-up duration is warranted.

Background: Insulin has emerged as an important determinant of food intake, energy expenditure, and weight control. This study examined the relationship between fasting serum insulin level and resting energy expenditure (REE) in a cross-sectional sample of nondiabetic schizophrenia patients., Methods: Subjects were recruited from an urban community mental health clinic. Each subject underwent a series of anthropometric measures and an indirect calorimetry measure. A fasting blood sample was taken for plasma glucose, serum insulin, and lipid profile., Results: Seventy-one subjects (54 male, 17 female) were included in the study. There was a significant positive relationship between REE and fasting serum insulin level (r = .39, p = .001). Stepwise multiple regression analysis was performed with various characteristics such as age, race, antipsychotic agent used, fat-free mass, BMI, waist circumference, waist-hip ratio, physical activity level, and fasting serum insulin as candidate predictors for REE. Only fat-free mass and insulin were able to enter into the regression model, which indicates that higher fat-free mass and higher fasting serum insulin level predict increased REE., Conclusions: A higher fasting serum insulin level is associated with an increased REE, which may prevent further weight gain in nondiabetic patients with schizophrenia.

Objective: Clozapine and olanzapine treatment has been associated with insulin resistance in non-obese schizophrenia patients. Much less is known regarding other agents such as quetiapine. The objective of this study was to compare matched olanzapine- and quetiapine-treated schizophrenia patients and normal controls on measures of glucose metabolism., Method: A cross-sectional comparison of quetiapine-treated and olanzapine-treated non-obese (body mass index < 30.0 kg/m2) schizophrenia subjects (DSM-IV) with matched normal controls using a frequently sampled intravenous glucose tolerance test and nutritional assessment was conducted from April 2002 to October 2004. Data from 24 subjects were included in the analysis (7 quetiapine, 8 olanzapine, 9 normal controls)., Results: There was a significant difference among groups for fasting baseline plasma glucose concentrations (p = .02), with olanzapine greater than normal controls (p = .01). The insulin sensitivity index (SI) differed significantly among groups (p = .039); olanzapine subjects exhibited significant insulin resistance compared to normal controls (p = .01), but there was no significant difference for quetiapine versus olanzapine (p = .1) or quetiapine versus normal controls (p = .40). SI inversely correlated with quetiapine dose (p = .0001) and waist circumference (p = .03) in quetiapine-treated subjects. Insulin resistance calculated by the homeostasis model assessment of insulin resistance (HOMA-IR) also differed significantly among groups (p = .03). The olanzapine group had a higher HOMA-IR level than normal controls (p = .01). There was a significant difference in glucose effectiveness (SG) among the groups (p = .049). SG was lower in the olanzapine group than in the quetiapine group (p = .03) and in the olanzapine group compared to normal controls (p = .049)., Conclusions: Our findings are consistent with our previous report that nonobese olanzapine-treated subjects showed insulin resistance, measured by both HOMA-IR and SI, and reduction in SG. Studies that include larger samples, unmedicated patients, and varying durations of antipsychotic exposure are necessary to confirm these results.

Background: The increasing prevalence of overweight and obesity has become a priority public health issue in the United States. Forty to 62% of people with schizophrenia are obese or overweight (1, 2). High morbidity and mortality in schizophrenia may be attributed to an unhealthy lifestyle such as poor diet, lack of exercise, smoking, and substance abuse (3). Obesity is associated with greater risk of developing hypertension, type 2 diabetes, coronary heart disease, stroke, death, and reduced quality of life compared with that found in the general population (4, 5). We performed a cross-sectional study evaluating the dietary intake of patients with schizophrenia or schizoaffective disorder treated with atypical antipsychotic agents., Methods: Dietary intake of 88 patients from an urban community mental health clinic was measured using a four-day dietary record. Nutritional variables included total energy intake, fat, protein, carbohydrate, cholesterol, fiber, sucrose, folate, calcium, sodium, zinc, alcohol and caffeine. Data were compared to the general population using data matched for age, gender, and ethnicity from the National Health and Nutrition Examination Survey (NHANES), 1999-2000., Results: The Body Mass Index (BMI) of the schizophrenia group (M = 31.3, SD = 12.67) was significantly greater than the NHANES group (M = 28.3, SD = 6.62) (p = .001). The schizophrenia group consumed significantly fewer calories, carbohydrate, protein, total fat, saturated fat, monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), fiber, folate, sodium and alcohol and significantly more caffeine than the NHANES group., Conclusions: The findings may suggest that obesity in schizophrenia patients is not solely related to food consumption, but perhaps other effects including medication side effects and reduced physical activity. Education and interventions for the schizophrenia population should focus more on overall lifestyle factors such as physical activity and healthy food choices.

Objective: We studied a sample of schizophrenia out-patients to test the hypotheses that serum homocysteine concentrations would correlate positively with measures of glucose metabolism., Method: Subjects underwent a nutritional assessment and fasting plasma, serum insulin and homocysteine tests., Results: Males had a significantly higher homocysteine levels than females (7.69 +/- 1.42 microM vs. 6.63 +/- 1.40 microM; P = 0.02). Comparing subjects with normal fasting glucose (NFG) (glucose < 100 mg/dl) and impaired fasting glucose (IFG) (> or = 100 mg/dl) subjects with IFG (mean 8.2 +/- 1.5 microM) had significantly higher homocysteine levels than those with NFG (mean 7.2 +/- 1.4 microM, P = 0.03). IFG was also associated with greater mean values for a Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) (P = 0.002) and diastolic blood pressure (P = 0.045)., Conclusion: The group with IFG had higher fasting serum homocysteine concentrations than those with NFG which supports a connection to an important cardiovascular risk factor.