Substance‐Abusing Schizophrenics: Do They Self‐Medicate?

In spite of having been formulated nearly two decades back, there is as yet no consensus on the validity of the clinically popular self-medication hypothesis (SMH) of substance use disorders in patients with dual diagnosis. SMH broadly proposes that patients use substances in a non-random fashion so that the psychopharmacologic characteristics of particular substances are used to alleviate a variety of psychiatric symptoms and emotional distress. In order to test the SMH empirically, it was broken down to five sub-hypotheses, which were tested in a group of dual-diagnosis schizophrenia (DDS) patients vis-à-vis a group of only-schizophrenia (S) patients (n = 22 each). The DDS group scored lower than the S group regarding general and some specific psychopathology. The DDS patients ascribed reasons for substance use more often for hedonistic pursuit but also for reduction in symptoms and distress. There was a trend for alcohol to be used more for self-medication purposes compared to opioids and cannabis. The perceived effects of these three substances were significantly different on several symptom/distress dimensions. Finally, there was some degree of "match" between symptom-oriented reasons for use of substances and the effect that was perceived. All of this evidence provides a consistent but modest support for the SMH for "some patients, some substances, and some symptoms." The implications are discussed.     

What's in a Self‐report? A Comparison of Pregnant Women with Self‐reported and Hospital Diagnosed Eating Disorder

The aim of this study was to examine how similar pregnant women with self‐reported lifetime eating disorder (ED) were to pregnant women with a hospital diagnosis of ED. A total of 83 731 pregnant women enrolled in the Danish National Birth Cohort reported on ED, and by linkage to the Danish health registers, hospital diagnoses of ED were obtained. Characteristics of women with self‐reported ED, hospital diagnosed ED and without ED were compared using chi‐square tests, t‐test and logistic regression models with robust standard errors. In total, 4.8% women reported ED, and 0.5% had a hospital diagnosis of ED recorded in the health registers. Women with self‐reported ED were comparable with women with hospital diagnosed ED on most reproductive and health characteristics, while they differed from women without ED concerning all characteristics studied. Our findings highlight that women with self‐reported ED have impaired function and adverse health outcomes, consistent with diagnosable ED. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.     

Self‐monitoring of blood glucose in type‐2 diabetes: what is the evidence?

BACKGROUND: There is a controversy about self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes who are not using insulin. Randomized trials are limited in duration, size, and validity. METHODS: Systematic search for randomized trials and observational studies published since 1990. For inclusion studies had to report on SMBG in type 2 diabetes managed with oral hypoglycaemic agents and/or diet alone, HbA(1c) or clinical outcome, have at least 50 patients and be of at least 6 months' duration. RESULTS: Three randomized trials with 1000 patients were included, though all had interventions differing in the amount of education on SMBG, and in the population studied. The two larger studies had statistically significantly lower HbA(1c) levels with SMBG. Thirteen observational studies had information on over 60,000 patients. Smaller studies had lower initial HbA(1c) and showed no association between SMBG and laboratory or clinical improvement. Larger studies tended to have higher initial HbA(1c) and did show an association between SMBG and laboratory or clinical improvement. Overall, improvement in glycaemic control with SMBG tended to be seen in studies with initial HbA(1c) above 8%. CONCLUSIONS: It is likely that SMBG is beneficial in some circumstances, for example as an educational tool, for patients with type 2 diabetes not using insulin who have poor glycaemic control. More information is needed at the level of the individual patient, rather than group means, and about timing and frequency of monitoring, response to those results, what constitutes effective patient education, and long-term clinical outcomes.     

Could Self‐Neglect in Older Adults Be a Geriatric Syndrome?

Self-neglect in older adults is a complex phenomenon characterized by inattention to health and hygiene, typically stemming from an inability or unwillingness to access potentially remediating services. Some aspects of self-neglect clinically resemble geriatric syndromes (e.g., falling, incontinence). The literature on self-neglect was comprehensively reviewed and its quality evaluated in the context of considering its candidacy for a geriatric syndrome. MEDLINE (1966-2004) was searched using self-neglect as a keyword. Using a "snowball" sampling strategy, associated terms (e.g., Diogenes' syndrome) were combined, selecting relevant papers and frequently cited references, assessing each one using specific criteria. Its candidacy for consideration for a geriatric syndrome was assessed based on the quality of data in four domains: multifactorial etiology, shared risk factors with other geriatric syndromes, association with functional decline, and association with increased mortality. The 54 articles reviewed included 24 case series, 13 theoretical articles, 11 observational studies, and six reviews; these were of highly variable methodological quality. The strongest evidence that self-neglect may be a geriatric syndrome includes its often multifactorial etiology, its clear independent association with increased mortality, and the fact that two other geriatric syndromes (cognitive impairment and depression) are risk factors for self-neglect. Self-neglect in older adults is a prevalent problem that appears to have at least some features of a geriatric syndrome. Insofar as the concept of geriatric syndrome has been a useful clinical and research paradigm to create interventions for vulnerable older adults, and no such strategies are available for this vexing and understudied clinical problem, future research is warranted in this area.     

Pain in Severe Dementia: Self‐Assessment or Observational Scales?

OBJECTIVES: To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data. DESIGN: Prospective clinical study. SETTING: Geriatrics hospital and a geriatric psychiatry service. PARTICIPANTS: All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3. MEASUREMENTS: Three self-assessment tools--the verbal, horizontal visual, and faces pain scales--were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales. RESULTS: Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88-0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45-0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25-0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales. CONCLUSION: Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.     

Does Self‐Rated Health Predict Survival in Older Persons with Cognitive Impairment?

OBJECTIVES: To determine whether baseline self-rated health (SRH) independently predicted survival in an older Canadian population and to investigate the role of cognition on the SRH-mortality relationship. DESIGN: Population-based prospective cohort study. SETTING: Ten Canadian provinces, community-based. PARTICIPANTS: A total of 8,697 community-dwelling participants aged 65 and older. MEASUREMENTS: Self-reported measures of overall health, physical function, comorbidities, and demographic characteristics were obtained by interview. Cognitive ability was ascertained using the Modified Mini-Mental State Examination (3MS). Participants were followed for their survival status from the initial interview in 1991 until October 31, 1996. RESULTS: Subjects with reports of poor SRH were significantly more likely to die during follow-up than those reporting good SRH, after adjusting for relevant covariates (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI)=1.24-1.53). SRH was also related to other measures of health status across levels of cognitive impairment. SRH remained a significant predictor of mortality in subjects with mild to moderate cognitive impairment (AHR=1.26, 95% CI=1.01-1.59) but not in those with severe cognitive impairment (AHR=1.00, 95% CI=0.76-1.31). CONCLUSION: This study supports the utility of SRH assessments in predicting survival of individuals with mild to moderate cognitive impairment. The findings highlight the potential role of complex cognitive processes underlying the SRH-mortality relationship.     

Can Encouraging Substance Abuse Patients to Participate in Self‐Help Groups Reduce Demand for Health Care? A Quasi‐Experimental Study

BACKGROUND: Twelve-step-oriented inpatient treatment programs emphasize 12-step treatment approaches and the importance of ongoing attendance at 12-step self-help groups more than do cognitive-behavioral (CB) inpatient treatment programs. This study evaluated whether this difference in therapeutic approach leads patients who are treated in 12-step programs to rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. METHODS: A prospective, quasi-experimental comparison of 12-step-based (N = 5) and cognitive-behavioral (n = 5) inpatient treatment programs was conducted. These treatments were compared on the degree to which their patients participated in self-help groups, used outpatient and inpatient mental health services, and experienced positive outcomes (e.g., abstinence) in the year following discharge. Using a larger sample from an ongoing research project, 887 male substance-dependent patients from each type of treatment program were matched on pre-intake health care costs (N = 1774). At baseline and 1-year follow-up, patients' involvement in self-help groups (e.g., Alcoholics Anonymous), utilization and costs of mental health services, and clinical outcomes were assessed. RESULTS: Compared with patients treated in CB programs, patients treated in 12-step programs had significantly greater involvement in self-help groups at follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge (22.5 visits) as patients treated in 12-step treatment programs (13.1 visits), and also received significantly more days of inpatient care (17.0 days in CB versus 10.5 in 12-step), resulting in 64% higher annual costs in CB programs ($4729/patient, p < 0.001). Psychiatric and substance abuse outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB programs, p < 0.001). CONCLUSIONS: Professional treatment programs that emphasize self-help approaches increase their patients' reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.     

Does Self‐Esteem Mediate the Relationship between Interpersonal Problems and Symptoms of Disordered Eating?

It has been proposed that interpersonal problems play a role in the maintenance of disordered eating because of an adverse effect on self‐esteem, which in turn encourages the pursuit of achievement in the valued domain of weight and shape. This study aimed to identify the types of interpersonal problems that are associated with disordered eating and to determine whether self‐esteem mediates the relationship between interpersonal problems and eating disorder symptoms. Female university students (n = 227) completed the Inventory of Interpersonal Problems‐32, Eating Disorder Examination Questionnaire and Rosenberg Self‐Esteem Scale. Regression analysis identified two forms of interpersonal problems that were associated with disordered eating: difficulties being sociable and being too dependent on the opinion of others. Self‐esteem mediated the relationship between interpersonal problems and overevaluation of weight and shape but did not mediate the relationship between interpersonal problems and dietary restraint. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.     

To Approach or Avoid Alcohol? Automatic and Self‐Reported Motivational Tendencies in Alcohol Dependence

Background: Motivational conflict is central to alcohol dependence, with patients reporting motivation to limit their drinking at the same time as urges to drink alcohol. In addition, dual process models of addiction emphasise the power of automatic cognitive processes, particularly automatic approach responses elicited by alcohol‐related cues, as determinants of drinking behavior. We aimed to examine the strength of automatic and self‐reported alcohol approach and avoidance tendencies among alcohol‐dependent inpatients relative to matched controls. Methods:enbsp; A total of 63 alcohol‐dependent patients undergoing detoxification and 64 light‐drinking controls completed a stimulus‐response compatibility (SRC) task, which assesses the speed of categorization of alcohol‐related pictures by making symbolic approach and avoidance movements. We also included modified versions of the SRC task to assess automatic motivational conflict, that is, strong approach and avoidance tendencies elicited simultaneously by alcohol‐related cues. Results: There were no differences between alcohol‐dependent patients and controls on the SRC task, although individual differences in the quantity of alcohol consumed before entering treatment were significantly positively correlated with the strength of approach (but not avoidance) tendencies elicited by alcohol‐related cues. Automatic approach tendencies were also positively correlated with self‐reported “approach” inclinations and negatively correlated with self‐reported “avoidance” inclinations. Conclusions: Although alcohol‐dependent patients and matched controls did not differ on automatic approach and avoidance tendencies elicited by alcohol‐related cues, individual differences in the quantity of alcohol consumed before entering treatment were associated with the strength of automatic approach tendencies elicited by alcohol cues.     

Self‐ and Informant Report of Financial Abilities in Patients with Alzheimer's Disease: Reliable and Valid?

OBJECTIVES: To evaluate the consistency, stability, and accuracy of reports by patients with Alzheimer's disease (AD) and their caregivers regarding the patients' premorbid and current financial abilities. DESIGN: Consistency of reports was assessed within patient/caregiver dyads and within control/control informant dyads. Stability of reports over a 1-month interval was assessed for each group: patients with AD, caregivers, controls, and control informants. Accuracy of each group's reports was evaluated in reference to patients' and controls' performance on a direct psychometric measure of financial capacity. SETTING: University medical center. PARTICIPANTS: Twenty patients with AD and 20 family caregivers; 23 controls and 23 family informants. MEASUREMENTS: The Prior Financial Capacity Form (PFCF) and the Current Financial Capacity Form (CFCF) were used. Parallel versions assessed self-report (patients, controls) and informant report (caregivers, control informants) at two visits 1 month apart. Patients with AD and controls were also administered the Financial Capacity Instrument (FCI), a direct assessment of the same abilities reported on the PFCF and CFCF. RESULTS: Patients with AD reported that they had more-intact current abilities than their caregivers reported. Patients with AD and their caregivers showed lower levels of stability over time on the PFCF and CFCF than did controls and their informants. Half of the patients with AD overestimated their current abilities relative to their FCI performance, whereas caregivers demonstrated both underestimation and overestimation errors. Controls and informants evidenced high levels of consistency, stability, and accuracy in PFCF and CFCF ratings. CONCLUSION: Patients with AD overestimate their financial abilities in comparison with the reports of their family caregivers. Both patients and caregivers' reports of patients' financial abilities showed limited stability and validity. The reliability and accuracy of self- and informant reports of financial abilities may be compromised in the context of dementia and caregiving, underscoring the need for direct assessment methods to augment self- and informant report in assessing functional decline in dementia.