Symptom Effects on Employment in a Structural Model of Mental Illness and Treatment: Analysis of Patients with Schizophrenia

BACKGROUND: There is a long tradition in the health and mental health economics literatures of estimating the impacts of disorders on employment and earnings. Several analyses have associated mental illness with poorer labor market outcomes, often using indicators of disorders to measure mental illness, but it is unclear to what extent unobserved medical treatment biases the estimated impacts of disorders on labor market outcomes. In this study we argue that in order to judge the true employment costs of mental illness and the potential benefits of treatment it is necessary to account for the structural relationship between treatment, symptoms, and employment outcomes. AIMS OF THE STUDY: The study proposes a structural model for understanding mental illness impacts on employment and empirically estimates one element of this structural model that links symptoms of schizophrenia to patients' employment status. In addition, we use our empirical estimates to simulate employment consequences of more effective treatment and reductions in symptom levels. EMPIRICAL METHODS: Our empirical analyses use a sample of 1,643 adults with a schizophrenia diagnosis. We predict the likelihood of three outcomes - not employed, employed in a sheltered or supported job, and employed in a non-supported job. Analyses include measures of demographic characteristics, illness history, location differences, and detailed symptom measures. RESULTS: We find that negative symptoms have a substantial adverse impact on participation in both non-supported jobs and in sheltered or supported jobs. The impacts on employment of other symptoms of schizophrenia are not as large, but significant effects are also found for symptoms of depression. Simulations suggest, however, that only one-third of consumers would be employed in any type of job even given a large reduction in symptom levels. DISCUSSION: Negative symptoms are particularly important for role functioning and employment. The marginal effect on employment of a reduction in negative symptoms is several times greater than the effect of a comparable reduction in positive symptoms. Moreover, the effect of an improvement in symptoms on employment is stronger for non-supported employment than for working in sheltered or supported employment. Although commonly measured symptoms of schizophrenia impact employment, greater control of symptoms alone is unlikely to lead to large increases in employment for persons with schizophrenia in the near term. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These findings suggest that improved treatment that results in reduced symptom levels will increase rates of employment among persons with schizophrenia, but that large employment impacts probably also require more effective rehabilitative therapies that target improvement in functioning. IMPLICATION FOR POLICY: Expansions of supported employment opportunities and removal of work disincentives in public income-support programs are two additional measures that may help to increase employment participation.     

Affective disorders: analysis of their comorbidity in the more frequent psychiatric disorders

Comorbidity is defined as the presence of two or more independent diseases in the same subject. This paper reviews the comorbidity of affective disorders with other mental disorders. We focus on the disorders of anxiety, schizophrenia, dependence on psychoactive substances, eating disorders, personality disorders and obsessive-compulsive disorder. To this end, we have carried out an extensive review that has taken account of numerous studies, as well as of different diagnostic orientations (categorical or dimensional). In general the presence of affective symptoms and/or disorders in the context of other mental pathologies is high. Moreover, comorbidity has a high transcendence with respect to clinical prognosis (worse response to treatments, greater symptomatic persistence, greater tendency to chronicity and greater risk of mortality) and the social consequences (decline in work performance and greater use of resources). Nonetheless, we must bear in mind that the analysis of the comorbidity of affective disorders in other mental disorders is complex and controversial, not only because of its high frequency, but also because of the existence of symptomatic overlap, scarcity of signs and pathognomonic symptoms, variability of diagnostic criteria, applied methodological differences, as well as a scarcity of longitudinal and prospective studies.     

First-episode psychosis: a clinical approach

BACKGROUND: Psychotic illnesses, such as schizophrenia and bipolar illness, are relatively common and clearly devastating diseases. Most scientific literature focuses on research and care of patients suffering from psychotic illnesses in the middle age-group; subsequently, the first episode or early stages of psychotic illnesses have been relatively ignored, especially the issues of early diagnosis and intervention. The purpose of this article is to highlight issues of first-episode schizophrenia for the family physician and to discuss (1) diagnosis, (2) neuropsychiatry research, (3) new medications, and (4) family issues. METHODS: To approach the issues of first-episode schizophrenia, we describe a case of a young woman who suffered her first episode of psychosis. Relevant literature related to the early stages of psychosis, including new pharmacologic treatments, is addressed. RESULTS: This report of our patient, a 19-year-old woman, illustrates the problems of a long prodromal phase of her illness, the use of medications that might have worsened her condition, and the successful use of new antipsychotic medications. Her family's issues as the patient went through this phase of her illness and recovery are reviewed. CONCLUSIONS: Patients at the outset of a psychotic illness are frequently first seen by a family physician. Familiarity with current diagnostic criteria and effectiveness of new treatments can lead to improved detection and overall outcome.     

The use of cholinergic precursors in neuropsychiatric diseases

Preclinical data suggest that cholinergic precursors such as choline or lecithin, increase levels of acetylcholine in specific brain structures, and under certain conditions may enhance cholinergic neurotransmission. A variety of neuropsychiatric diseases including tardive dyskinesia. Huntington's chorea, ataxias, Tourette's syndrome, schizophrenia, affective illness, and senile dementia of the Alzheimer type, has been implicated with a general underactivity of central cholinergic mechanisms. Recent studies have investigated the possibility that cholinergic precursor loading strategies may provide viable treatments for these disorders of presumed cholinergic underactivity. Extensive data demonstrate that the symptoms of tardive dyskinesia can be reduced by choline or lecithin, whereas investigations in other disorders have met with mild success, at best, or are still in preliminary stages. Further controlled studies with choline or lecithin using broader dose ranges, longer durations of treatment, and concomitant administration of agents which may increase the release of acetylcholine are warranted.     

Bipolar illness in primary care: an overview

Primary care providers are in the front line of detecting and diagnosing psychiatric illness. Managed care barriers to direct psychiatric treatment have made it necessary for primary care providers to increase their sophistication in the recognition of psychiatric disorders. Primary care providers often formulate provisional diagnoses and initiate treatment or specialty referral in spite of the time constraints of the primary care setting. The patient presenting in primary care with an affective disturbance must be evaluated for a major mood disorder, which includes unipolar and bipolar illness. Research has shown that more patients than previously estimated have milder forms of bipolar illness disorder, such as bipolar type II and cyclothymia. Patients with these milder forms of bipolar are less likely to present for treatment in a psychiatric setting and more likely to share symptoms of the illness in a primary care setting. This article provides an overview for the primary care provider in the detection, assessment, and treatment of bipolar patients with an emphasis on the differentiation of unipolar and bipolar depression.     

Predictors and course of vocational status, income, and quality of life in people with severe mental illness: a naturalistic study

Due to high unemployment rates, people with mental illness are at risk of poverty and are deprived of the social and psychological functions of work, such as the provision of social support, structuring of time, and self-esteem, with a negative effect on their perceived quality of life (QoL). Two distinct processes are held responsible for the low work force participation of people with mental illness: 'Social underachievement' and 'social decline'. Social underachievement signifies that, due to early illness onset, the educational attainment of people with mental illness is low and entry to the labor market fails. Social decline, on the other hand, describes the loss of competitive employment after illness onset, followed by prolonged periods of unemployment and difficulties to re-enter the labor market. This study examines how social underachievement and decline are reflected in the course of vocational status, income, and QoL of people with severe mental illness in the years after a psychiatric admission in a naturalistic longitudinal design. A total of 176 participants diagnosed with schizophrenia or affective disorders were interviewed during an index hospitalization in two large psychiatric hospitals in Zurich. Follow-up interviews were conducted 12 and 30 months after. Random coefficient models (multilevel models) were used to examine simultaneously the predictors and course of the variables of interest. A low number of psychiatric hospitalizations, a higher educational degree, a diagnosis of schizophrenia, and years of work experience predicted a higher vocational status. Vocational status decreased in first-admission participants with prolonged hospitalizations during the follow-up period. Income did not change over time and was positively influenced by a higher age of illness onset, competitive employment, higher education, and not having had a longer hospitalization recently. Subjective QoL significantly improved and was rated higher by people with any kind of employment than by participants without a job. Participants with an affective disorder, those with few hospitalizations but a recent inpatient stay of longer duration, showed lower QoL. Including employment issues early in treatment is especially important for people with an early illness onset and those with more severe forms of psychiatric disorder. A life course perspective enhances the understanding of patients' vocational potential and needs for support.     

Instrumental psychosis: the Good Soldier Svejk syndrome

The possession of severe mental illness, mainly schizophrenia and affective psychosis, may be perceived in positive terms. We have identified a group of patients, most of them with a history of previous psychotic disorder, who present with deliberately created symptoms and behaviour, and who are defined as having instrumental psychosis. Because most such patients have had a psychotic disorder in the past the symptoms are very like those of a real psychosis. A parallel is drawn with the fictional anti-hero of the Czech nation, the Good Soldier Svejk, who demonstrated both real and instrumental psychosis. A rating scale, the 'pseudopsychosis inventory', was devised to identify the main components of this disorder and was applied in 15 consecutive patients presenting with putative psychotic disorders in whom assessment could be made by two raters within five days. The inter-rater reliability of the items of the scale was good (intra-class correlation coefficient 0.68). An epidemiological study with this scale in 45 patients with a putative psychotic disorder suggested the presence of instrumental psychosis in 2.     

Somatotyping of schizophrenic and affective disorder patients

INTRODUCTION: Constitutional traits have been found to show a distinct relevance to major psychiatric disorders. Syndromal modified expressivity is also closely related to somatotypic constitution. In this view somatotyping appears valuable in diagnosis and prognosis of mental disorders. AIM: The present study was conducted in an attempt to outline somatotypic characteristics of schizophrenia and affective disorders with the aim of providing a logical basis for diagnosis of these major psychiatric disorders. MATERIAL AND METHODS: The somatotype of 54 schizophrenic and 68 affective disorder inpatients who fulfil the DSM-IV criteria for schizophrenia (subjects with schizophreniform, schizoaffective, schizoid and schizotypal personality disorders were excluded from the sample) and affective disorder (bipolar and unipolar) was assessed using the Health-Carter anthropometric method. RESULTS: The overall assessment of the somatotypes determined both groups as endomorphs mesomorphs with somatotype components 4.50-4.44-1.90 for schizophrenic patients and 5.87-5.40-0.36 for affective disorder patients. The difference between the two groups was statistically significant for any of the somatotype components. CONCLUSION: It is suggested that the constitutional and somatotypic characterization appears reasonable element in the multifactorial analysis of diagnostic decisions in these major psychiatric disorders.     

The Northern Ireland Early Onset Psychosis Study: Phenomenology and Co-morbidity in the First 25 Cases

Diagnosing psychotic disorders in young people is difficult. High rates of co-morbidity may be one reason for this difficulty, but it may also be the case that current diagnostic categories are not the most useful when approaching the care of young people with psychotic symptoms. The Northern Ireland Early Onset Psychosis Study is the first study to investigate psychotic disorders in children and adolescents in this region. Young people presenting with psychotic symptoms with onset before their 18th birthday were prospectively ascertained over a three-year period (2001-2004). Those who provided informed consent were subject to a diagnostic interview using the Kiddie-Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version. Twenty-five young people have completed the full assessment process to date. Ten young people met criteria for schizophrenia, 11 for affective psychosis, two for schizoaffective disorder and two for schizophreniform disorder. Twenty-one (80%) subjects also fulfilled criteria for at least one other DSM-IV diagnosis. In conclusion, whilst all subjects met criteria for one or other psychotic disorder, co-morbidity was common in this clinical sample. Greater awareness of the difficulties encountered when trying to reach a diagnosis in this age group may help to improve treatment outcomes.     

Primary affective disorders.

This paper reviews the diagnosis and medical treatment of the major affective disorders. Patients with severe mood disturbances are frequently seen by the family physician. The diagnosis may be delayed since the patient may focus predominantly on somatic concerns which may mimic physical illness. The characteristics, course, and differential diagnosis of depression and mania are discussed. Antidepressants and lithium therapy greatly improve the prognosis of these disorders; monoamine oxidase inhibitors and neuroleptics are indicated for special subtypes of depression. Dosage schedules, interactional effects, adverse and toxic effects are reviewed for tricyclic antidepressants and lithium.     

Social function in schizophrenia and schizoaffective disorder: Associations with personality,symptoms and neurocognition

Background

Research has indicated that stable individual differences in personality exist among persons with schizophrenia spectrum disorders predating illness onset that are linked to symptoms and self appraised quality of life. Less is known about how closely individual differences in personality are uniquely related to levels of social relationships, a domain of dysfunction in schizophrenia more often linked in the literature with symptoms and neurocognitive deficits. This study tested the hypothesis that trait levels of personality as defined using the five-factor model of personality would be linked to social function in schizophrenia.

Methods

A self-report measure of the five factor model of personality was gathered along with ratings of social function, symptoms and assessments of neurocognition for 65 participants with schizophrenia or schizoaffective disorder.

Results

Univariate correlations and stepwise multiple regression indicated that frequency of social interaction was predicted by higher levels of the trait of Agreeableness, fewer negative symptoms, better verbal memory and at the trend level, lesser Neuroticism (R² = .42, p < .0001). In contrast, capacity for intimacy was predicted by fewer negative symptoms, higher levels of Agreeableness, Openness, and Conscientiousness and at the trend level, fewer positive symptoms (R² = .67, p < .0001).

Conclusions

Taken together, the findings of this study suggest that person-centered variables such as personality, may account for some of the broad differences seen in outcome in schizophrenia spectrum disorders, including social outcomes. One interpretation of the results of this study is that differences in personality combine with symptoms and neurocognitive deficits to affect how persons with schizophrenia are able to form and sustain social connections with others.

     

Work Productivity in Psychiatry

This article contrasts trends in addressing work productivity in severe mental illnesses (SMI) such as schizophrenia and in affective disorders. Citations from searches of 8 reference databases were reviewed.The negative impact of SMI on employment is indisputable, as is the fact that people with these disorders could be employed more frequently than is the case. For those with SMI, work rehabilitation treatment models have been developed, but their implementation in disease management programs has lagged behind those of other diseases. In contrast to the situation with SMI, treatment outcomes in affective and anxiety disorders have been defined primarily in terms of symptom relief and interpersonal functioning. Attention to work productivity has emerged more recently as employers have become important stakeholders in healthcare decision making. Since most patients with affective disorders are already in the work force, some work productivity initiatives and outcomes developed for SMI may not be appropriate for patients with affective disorders. Attention to work productivity has not been systematically incorporated into treatment planning for affective disorders, and specific work-related psychiatric interventions are not yet available.In conclusion, the cost effectiveness of work productivity interventions in psychiatry requires their integration into comprehensive disease management programs. In making resource allocation decisions, appropriate incorporation of work productivity within a larger ethical framework of healthcare decision making is essential. The furtherance of work productivity initiatives in psychiatry requires collaboration among numerous stakeholders in professional education, service delivery and research.     

Occupational asthma with paroxysmal atrial fibrillation in a diamond polisher.

We present a case of a diamond polisher who developed occupational asthma as a result of prolonged exposure to various potent and well-recognized asthma-inducing agents, including cobalt dust. Although the patient was seen by various medical professionals during the initial course of his illness and given an early diagnosis of a respiratory condition, there were no attempts to evaluate the nature of his work, and therefore to establish a possible causal relationship with his exposures. This case clearly illustrates the importance of such an assessment. The ultimate fate of this patient (he had to retire from his job with a chronic and permanent illness) could have been avoided by early environmental intervention. In addition, this case illustrates a possible complication of asthma, that is, a severe cardiac arrhythmia. In this case, both the patient's symptoms and the prescribed medications contributed to worsening of the patient's underlying condition. Early diagnosis and intervention of this patient's work practices could have avoided this complication.     

Mental illness and the aged stranger

Sociological investigations of mental illness in older populations have been largely concerned with the causes and consequences of morale and life satisfaction. Satisfaction with life and "good morale" are widely viewed as reasonable indicators of mental health. Apart from the definitional problems inherent in this approach, the focus on morale has effectively diverted greater research attention from more serious issues of mental health in older populations, such as schizophrenia, personality disorders, and depression. The intent of this paper is to evaluate the dominant mental health paradigms within social gerontology; to synthesize some existing threads of a political economy/social control approach to these issues; and, finally, to argue that the act of growing old in capitalist societies brings increased risk of mental illness not because of drift, selection, or stress but, rather, because of the exclusion of the aged from labor markets and the physical and ideological "strangeness" of the aged.     

Atypical Antipsychotics and Metabolic Syndrome in Patients with Schizophrenia: Risk Factors,Monitoring, and Healthcare Implications

Background

Metabolic syndrome is a leading cause of morbidity and mortality in patients with schizophrenia, with a prevalence rate double that of nonpsychiatric populations. Given the amount of evidence suggesting a link between atypical antipsychotic medications and metabolic syndrome, several agencies have recommended regular clinical monitoring of weight, symptoms of hyperglycemia, and glucose in chronically medicated patients with schizophrenia.

Objectives

To summarize the current literature on atypical antipsychotic-induced metabolic syndrome in patients with schizophrenia, outline some of the molecular mechanisms behind this syndrome, identify demographic and disease-related risk factors, and describe cost-effective methods for surveillance.

Discussion

The differential prevalence of metabolic syndrome associated with various atypical antipsychotic medications has been evidenced across numerous studies, with higher effects seen for certain antipsychotic medications on weight gain, waist circumference, fasting triglyceride level, and glucose levels. Given the association of these symptoms, all atypical antipsychotic medications currently include a warning about the risk of hyperglycemia and diabetes, as well as suggestions for regular monitoring. Despite this, very little data are available to support adherence to these monitoring recommendations. Lack of awareness and resources, diffusion of responsibility, policy implementation, and organizational structure have all been implicated.

Conclusion

The treatment of schizophrenia involves a balance in terms of risks and benefits. Failing to treat because of risk for complications from metabolic syndrome may place the patient at a higher risk for more serious health outcomes. Supporting programs aimed at increasing monitoring of simple laboratory and clinical measures associated with metabolic syndrome may decrease important risk factors, improve patients'' quality of life, and reduce healthcare costs.Despite treatment advances in prevention, cardiovascular disease (CVD) remains the leading cause of mortality globally. CVD is responsible for 30% of all deaths and represents one of the leading long-term health considerations in the population as a whole.1 CVD is also the most common cause of natural mortality in schizophrenia, accounting for a total of 34% of deaths among male patients and 31% of deaths in female patients and is surpassed only by suicide.2 In fact, it has been estimated that the prevalence of dyslipidemia, hypertension, obesity, and type 2 diabetes is approximately 1.5 to 2 times higher in individuals with schizophrenia and other serious mental illness compared with the general population.3 Although the exact prevalence of metabolic syndrome in adults with schizophrenia varies greatly (between 20% and 60%), common estimates typically place this at twice that of the normal healthy population.4     

Schizophrenia in Afro-Caribbean immigrants.

Hospital admission rates for schizophrenia are higher in Afro-Caribbean immigrants to Britain than in the white British-born population. However, the reported differences in incidence and prevalence could be due to confounding variables: the diagnosis of schizophrenia might not carry the same prognostic implications in the two groups; and the differences in formal admission rates might not persist when demographic and diagnostic differences are allowed for. The case-notes of 50 Afro-Caribbean immigrants and 41 British-born white patients with a hospital diagnosis of schizophrenia were examined retrospectively, the average period covered being 12 years. There were no differences in the number of readmissions, but in the Afro-Caribbean group readmissions were shorter. Involuntary admissions were twice as common in Afro-Caribbeans and this excess was not explained by differences in age, sex, or type of illness. The reported excess of schizophrenia in Afro-Caribbean immigrants to Britain is real, but the illness seems to run a milder course than in the white British-born population.     

Affective temperaments: from neurobiological roots to clinical application

The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) has grown to be a clinically important outcome measure in the diagnosis and the clinical course of mood disorders. However, temperaments, which represent the biologically stable core of personality, are not just antecedents of major affective disorders, but also serve as a reservoir of genetically advantageous traits for the survival of different cultures. The rapidly growing body of research in psychiatric and non-psychiatric fields even raises the question of temperament as a common root in psychiatric and somatic disorders, providing a new meaning for the construct of psychosomatic disorders. In this review we aim to summarize current knowledge on both the neurobiological background and clinical importance of affective temperaments including implications for future research.     

Sick but healthy: bariatric patients and the social construction of illness and disability

Bariatric (weight loss) surgery modifies the digestive system, which produces impairments and symptoms which might be considered illness or disability. Bariatric patients, however, do not view themselves as ill or disabled, but healthier than before surgery. For this study, 35 bariatric patients – from a clinic located in the Midwestern United States – were interviewed to investigate how moral and medical discourses surrounding obesity impact how patients experience their bodies after bariatric surgery. While previous literature on bariatric patients has explored discourses of medicine, stigma and discipline, fewer have analysed how patients interpret physiological symptoms. Patients often reduce or discontinue medications for chronic illness after bariatric surgery, then replace them with a strict regimen of dietary supplements. Even though these supplements are taken to manage an impaired digestive system, they do not carry the same moral weight as medications for chronic illness. Patients also experience painful and humiliating symptoms after bariatric surgery. Bariatric patients interpret symptoms not as illness, but as important disciplinary tools to lose weight. These findings have implications for the social construction and experience of illness and disability in the context of fat stigma, health morality and biomedicalisation.     

The importance of early treatment of schizophrenia

It is extremely important to treat schizophrenia as soon as possible after the onset. With delay in effective treatment, patients may be at increased risk for brain volume loss with adverse implications for long-term treatment outcomes. Providers should not try to "instruct" patients with schizophrenia, who often have impaired verbal learning abilities, about the necessity of adhering to their medication regimen, but instead should try to demonstrate that the treatment can effectively improve their lives. To this end, it is crucial to find a medication at a dose that relieves psychotic and affective psychopathology as quickly as possible. To optimize treatment adherence, it seems more practical for providers to help patients with schizophrenia feel subjectively better and recognize improvement than to impress them with the logic of the argument for taking medications. In treating schizophrenia, physicians also should be involved and accessible to patients and caregivers. Providers should treat their patients with respect, express their viewpoint succinctly and consistently, and make clear that the betterment of the patient is their goal.     

Tardive dyskinesia in elderly patients: an update

The use of antipsychotic agents can be limited by side effects, particularly extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). These neurologic movement disorders can occur early in the course of treatment (often as EPS) or as a more latent effect (TD). TD can be debilitating, and several patient-related and treatment-related factors have been associated with an increased risk for its development. Of these, older age has been strongly linked to TD. The advent of novel antipsychotics for the treatment of schizophrenia and severe behavioral disorders permits the use of such agents with reduced risk of EPS and TD. Most clinical trials of the novel antipsychotics have enrolled younger patients, but some data on their efficacy and safety in the elderly are now available. This article reviews the relationship between TD and aging and its treatment in elderly patients.