Working with reactant patients: are we prescribing nonadherence?

Objective: In spite of high levels of antidepressant nonadherence frequently observed among depressed samples, relatively little research has investigated psychosocial predictors of adherence. Fostering greater collaboration in depression treatment to increase adherence has been advocated, but this strategy has not been adequately studied. The aim of this study was to examine the interaction of provider collaboration and patient reactance in the prediction of antidepressant adherence during the acute treatment phase. Method: Fifty outpatients diagnosed with major depressive disorder beginning antidepressant treatment within psychiatry clinics of the VA San Diego Healthcare System comprised the study sample. Patients were administered questionnaires following their medication evaluations to measure predictor variables. Antidepressant adherence was assessed via brief telephone interviews 3, 6, 9, and 12 weeks after treatment initiation. The roles of provider collaboration, patient reactance, and their interaction in adherence were examined using multiple regression analyses. Results: The interaction between provider collaboration and patient reactance accounted for 18.3% of the variance in 3‐week adherence (P<.01). Among more reactant patients, greater levels of collaboration predicted better adherence, whereas among patients lower in reactance less collaboration predicted better adherence. No relationships were observed beyond the initial 3 weeks of treatment. Conclusions: This study demonstrates that interpersonal process variables are important in influencing antidepressant adherence and challenges the advocacy of more collaboration in antidepressant treatment as a “blanket strategy.” Establishing a more collaborative set with reactant patients may ensure greater early treatment adherence, a critical period during which antidepressants have typically not yet taken effect. Depression and Anxiety, 2009. © 2008 Wiley‐Liss, Inc.     

Symptom perception and functional morbidity across a 1-year follow-up in pediatric asthma

The purpose of this study was to examine the association between asthma symptom perception measured during a 5-6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV(1)). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7-17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each "subjective" guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV(1). An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV(1)) and a lower proportion of SM blows (using FEV(1)) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV(1) more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception.     

Ethnic Differences in Somatic Symptom Reporting in Children With Asthma and Their Parents

ObjectivesThe purpose of this study is to examine the association between child and parent somatic symptom reporting and pediatric asthma morbidity in Latino and non-Latino white children.MethodThe study consists of 786 children, 7 to 15 years of age, in Rhode Island (RI) and Puerto Rico. Children's and parents' levels of general somatic symptoms were assessed with well-established self-report measures. Clinician-determined asthma severity was based on reported medication use, asthma symptom history, and spirometry results. Asthma-related health care use and functional morbidity was obtained via parent self-report.ResultsChild and parent reports of general somatic symptoms were significantly related to pediatric asthma functional morbidity when controlling for poverty, parent education, child's age, and asthma severity. In controlling for covariates, Latino children in RI reported higher levels of somatic symptoms than Island Puerto Rican children, and RI Latino parents reported more somatic symptoms than RI non-Latino white parents (p < .05).ConclusionsThis study replicates and extends to children in previous research showing higher levels of symptom reporting in Latinos relative to whites. Results also provide new insight into the relation between general somatic symptom reports and pediatric asthma. Ethnic differences in somatic symptom reporting may be an important factor underlying asthma disparities between Latino and non-Latino white children.     

Asylee perspectives on psychotherapies for posttraumatic stress

Asylees (i.e., asylum seekers) have a higher prevalence of mental health concerns, particularly posttraumatic distress, than the general population due to both their exposure to traumatic experiences and prolonged uncertain status in a new country. Meta-analyses of randomized controlled trials with asylees have found that culturally adapted cognitive behavioral therapy (CA-CBT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET) are efficacious in treating trauma-related symptoms and posttraumatic stress disorder (PTSD); however, treatment utilization remains low. Thus, it is imperative to determine what PTSD interventions are effective, credible, and acceptable for asylees. We employed structured virtual interviews with 40 U.S. asylees from diverse countries living with one or more symptoms of PTSD. Participants were asked about treatment engagement, perceived barriers to treatment, goals for psychotherapy, and perceptions of the effectiveness and difficulty of engaging in CA-CBT, EMDR, NET, and (non–exposure-based) interpersonal therapy (IPT) for PTSD. Participants perceived IPT to be significantly less difficult than all exposure-based treatments, with medium effect sizes, ds = 0.55–0.71. A qualitative analysis of asylees’ comments provided valuable insights into how they think about these treatments. Ways in which these results can be considered when informing recommendations for improving interventions for asylees are discussed.     

Asthma symptom perception and obesity in children

This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity.For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children.These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.     

Up-regulation of osteopontin and alphaBeta-crystallin in the normal-appearing white matter of multiple sclerosis: an immunohistochemical study utilizing tissue microarrays

Tissue microarrays assembled from control and multiple sclerosis (MS) brain tissue have been used to assess the expression patterns and cellular distribution of two antigens, the proinflammatory cytokine osteopontin and the inducible heat shock protein alphaBeta-crystallin, which have previously been implicated in MS pathogenesis. Tissue cores were taken from paraffin-embedded donor blocks containing chronic active or chronic inactive plaques and normal-appearing white matter (NAWM) in seven MS cases, and white matter (WM) in five control cases. Expression patterns of both proteins were assessed against myelin density and microglial activation in the different tissue categories. Both proteins showed increased expression in all categories of MS tissue compared with control WM. The results indicate progressive up-regulation of expression of osteopontin with increased plaque activity, while elevation of alphaBeta-crystallin expression in MS tissue was independent of demyelination. In MS NAWM a significant correlation was observed between high levels of expression of osteopontin and alphaBeta-crystallin. Osteopontin expression was predominantly confined to astrocytes throughout MS tissues. alphaBeta-crystallin was expressed on astrocytes, oligodendrocytes and occasionally on demyelinated axons. Taken together, these data indicate a wider distribution of osteopontin and alphaBeta-crystallin in MS tissues than previously described and support their proposed role in MS pathogenesis.     

Rejection sensitivity and multiple group memberships: The moderating role of an oxytocin receptor gene polymorphism

Rejection sensitivity is a cognitive-affective processing disposition that has been linked to interpersonal difficulties. In this regard, the neuropeptide hormone, oxytocin, is thought to underlie social cognitions and behaviors that promote social affiliation. A single nucleotide polymorphism (SNP) on the oxytocin receptor gene (OXTR), in which guanine (G) is substituted for adenine (A), has been associated with less support-seeking behaviors. In the current study, among 376 undergraduate students, it was shown that the relationship between rejection sensitivity and depressive symptoms was mediated by multiple group memberships. Furthermore, the relation between rejection sensitivity and group memberships was only evident among individuals possessing the A allele on the OXTR gene. These findings further support the psychosocial deficits characteristic of individuals possessing the OXTR polymorphism, which in turn is linked to poor mood.