Thesis advisor: Judith Shindul-Rothschild / Clinical Characteristics Of People In Randomized Clinical Trials Of First Episode Schizophrenia Spectrum Disorders: Attrition Versus Non-Attrition Groups Submitted by Joanne D. Wojcik PhD, RN Dissertation Advisor Judith Shindul-Rothschild, PhD, RN Abstract Background: Early identification of psychosis and intensive treatment has been the focus of the treatment of people with a first episode (FE) schizophrenia spectrum disorder (SSD). Attrition rates in studies of people in the first episode are high, which makes it difficult to understand the meaning of the study outcomes. High attrition rates affect the validity of a study by decreasing its power and the study's ability to detect differences between treatment groups. Additionally, the people who leave a study may be different from those who stay in demographic, illness and treatment characteristics. Method: This study is a secondary analysis of a group of FE SSD participants enrolled in one of three separate double-blind, randomized, drug trials. The variables were first analyzed across the three drug study data sets to determine if the patient populations are comparable across the three studies to allow for the merging of the data. Exploratory and descriptive statistics of study participants were conducted in a comparison of the three studies, for the merged group, and for the attrition and non-attrition groups. Effect sizes (Cohen's d) were calculated for each variable in the individual studies and in the merged dataset for the magnitude of difference between the attrition and non-attrition groups. Results: The three studies were merged after analysis found no consistent difference in demographic and illness characteristics between the three studies. There was no significant difference between the attrition and non-attrition groups in the merged data in demographic and illness characteristics. Treatment characteristics consistently found lack of efficacy and patient withdrawal of consent to be the two most frequent reasons for attrition from the studies. In addition, participants receiving a typical agent were less likely to complete the study. Effect size calculations found attrition group to more likely be Caucasian, with a lower median income. The attrition group had more years of education, but was not in school in the year previous to hospitalization. Conclusion: Historically, attrition is a major problem in clinical trials of people in a first episode of schizophrenia spectrum disorders. People receiving typical antipsychotic medication are more likely to leave a study. Most common reasons for attrition include lack of efficacy and withdrawal of consent / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

PURPOSE: To generate a theory of the psychosocial processes influencing weight management among persons newly prescribed atypical antipsychotic medications. RESEARCH QUESTIONS: 1. What influences weight management in persons with first-episode psychosis who are newly prescribed atypical antipsychotic medications? 2. How is weight management facilitated in persons with first-episode psychosis who are newly prescribed atypical antipsychotic medications? 3. What psychosocial processes impede weight management in persons with first-episode psychosis who are newly prescribed atypical antipsychotic medications? METHODS: A qualitative, grounded theory research design was used to guide the study. Semi-structured interviews were the method of data collection and analysis was performed using constant comparison. SAMPLE & SETTING: A sample of 10 participants with first-episode psychosis prescribed atypical antipsychotics for at least eight weeks and six participants with a diagnosis of chronic schizophrenia who have been taking atypical antipsychotic medication for at least three years were obtained from an Outpatient Psychiatric program using theoretical sampling. FINDINGS: Contextual factors influencing weight management were: accessibility to resources, unstructured lifestyle, and others’ perception of their weight. Conditions influencing weight management were: rapid weight gain, insatiable hunger, and a lack of motivation boosters. Participants’ early responses to actions influencing weight gain management included discontinuing medications, choosing lower calorie foods, using walking in daily activities as exercise, accepting weight gain, and trying to manage weight but giving up. The consequences revealed from data analysis were contemplating weight management and not trying, as the barriers to weight management substantially exceeded the facilitators and many procrastinated in taking on any weight management strategies. CONCLUSION: The theoretical framework developed in this study can assist with the understanding and management of weight gain among this unique population. / Thesis (Master, Nursing) -- Queen's University, 2010-09-06 00:12:11.781

Although many advances in the treatment of schizophrenia have been made over the past decade, little is known about the process of recovery from a first episode of schizophrenia (FES). To date, the study of recovery in the field of mental health has focused on long-term mental illness. This in depth qualitative study drew upon Charmaz’s (1990) constructivist grounded theory methodology to address the following questions: How do individuals who have experienced a FES describe their process of recovery? How does an identified individual (e.g. friend, family member, teacher, or clinician) describe their role during the participant’s process of recovery, and their perception of the recovery process? Ten primary participants (who self-identified as recovering from a FES) had two interviews; in addition, there was a one-time interview with a secondary participant, for a total of 30 interviews. Data collection sources included participant semi-structured interviews, participant selected personal objects that symbolized their recovery, and clinical records. The results provide a substantive theory of the process of recovery from a FES. The emergent process of recovery model for these participants is comprised of the following phases: ‘Lives prior to the illness’, ‘Lives interrupted: Encountering the illness’, ‘Engaging in services and supports’, ‘Re-engaging in life’, ‘Envisioning the future’; and the core category, ‘Re-shaping an enduring sense of self,’ that occurred through all phases. A prominent distinctive feature of this model is that participants’ enduring sense of self were reshaped versus reconstructed throughout their recovery. The emergent model of recovery from a FES is unique, and as such, provides implications for clinical care, future research, and policy development specifically for these young people and their families.

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Introduction: Impaired neurocognition, especially social cognition, predicts disability in schizophrenia. Early intervention to target impairment is theoretically attractive as a means to minimise chronic disability. Many trials confirm that Cognitive Remediation (CR) produces meaningful, durable improvements in cognition and functioning but few interventions remediate social cognition or focus on the early stages of schizophrenia. Methods: A systematic review and meta-analysis of 11 randomised controlled trials (RCTs) of CR in first episode psychosis (FEP) was completed. A randomised controlled pilot trial was then conducted to investigate a combined CR and social cognition training (CR+SCT) intervention in FEP compared to CR alone, assessing cognition, functioning and symptoms at baseline and follow-up. Qualitative feedback was also obtained in a nested feasibility and acceptability study to assess engagement, intervention suitability and attrition. Results: In the systematic review and meta-analysis, random effects models revealed a non-significant effect of CR on global cognition in FEP. However, there was a significant effect on functioning and symptoms, which was larger in trials with adjunctive psychiatric rehabilitation and small group interventions. In the pilot trial, the CR+SCT group had significantly better social functioning scores post-treatment, especially on the interpersonal relationships scale, however there was no significant effect on social cognition. CR+SCT also improved visual learning and set-shifting. There was no specific effect on symptoms. The nested feasibility and acceptability study found CR and CR+SCT to be acceptable and feasible for early intervention in psychosis service users, with high engagement rates and high user-reported satisfaction. Users perceived improvements in neurocognition and reported using strategies learnt during CR in daily life. Conclusions: Meta-analysis suggests that CR is beneficial in FEP. Evidence from the pilot trial shows that a CR intervention enhanced with SCT can improve functioning more than CR alone and that such an intervention is feasible and acceptable. A larger RCT is required to explore the full benefits of a CR+SCT intervention compared to CR and treatment as usual.

Left atrial myxomas are the most common type of benign primary cardiac tumor. Patients can present with generalized symptoms, such as fatigue, symptoms from obstruction of the myxoma, or even embolization of the myxoma causing distal thrombosis. We describe a case with several-month duration of syncopal episodes that occurred after coughing and with exertion. Computed tomography of the chest showed a 6.1 cm by 4.5 cm mass in the left atrium, later evaluated with an echocardiogram. Cardiothoracic surgery removed the mass, and it was determined to be an atrial myxoma. It is important for an internist to be able to diagnose an atrial myxoma because of the risks associated with embolization and even sudden death as myxoma can block blood supply from atrium to ventricle.

BACKGROUND: Soft neurological signs (SNS) are subtle, nonspecific neurological abnormalities that are present in first episode psychosis (FEP) patients. SNS are associated with clinical variables such as poor long term psychosocial functioning, executive functioning, and positive and negative symptomology. However, few studies have evaluated treatment responsiveness with respect to SNS. OBJECTIVE: To investigate whether SNS show: 1.) baseline and longitudinal differences between both diagnostic groups (schizophrenia (FEP-SZ), non-schizophrenia FEP-NSZ, and healthy controls (HC)) and treatment outcome (week 26 and year 1); 2.) relationships to clinical measures; 3.) predictive characteristics of treatment response. METHODS: SNS scores (Neurological Evaluation Scale) were obtained for 312 FEP (236 FEP-SZ and 76 FEP-NSZ subjects and 169 HC subjects and for subjects classified as treatment responsive and non-responsive at week 26 (N=105, N=105) and year 1 (N=101, N=97), respectively. Diagnostic group and treatment responsiveness group comparisons were assessed with ANCOVA and logistic regression models and both were co-varied for age, sex, race, and handedness. Baseline and longitudinal SNS relationships to clinical variables were determined using Spearman correlations and repeated measures correlations, and both were corrected by False Discovery Rate. Linear mixed effects model was utilized to analyze the data longitudinally. RESULTS: Baseline cognitive perceptual SNS measures had the greatest effect size differences, were predictive of group membership, and differentiated the two proband groups with FEP-SZ having worse SNS scores. Baseline cognitive perceptual SNS did not significantly predict treatment response at week 26 or year 1, but changes in cognitive perceptual at week 26 was predictive of treatment responsiveness at week 26 and year 1. Longitudinally, SNS scores drop in both FEP groups and treatment groups. The FEP-SZ group showed greater longitudinal within subject correlations than FEP-NSZ. SNS scores were only differentiated between year 1 outcome groups at week 8. There were greater longitudinal within subject correlations for the responsive group. CONCLUSION: Our findings indicate that there are baseline group differences and that changes in cognitive perceptual SNS scores at week 26 are predictive of treatment responsiveness at week 26 and year 1. / 2019-07-03T00:00:00Z

While a comorbid relationship between substance abuse and depression in Caucasian adults has been widely documented, comorbid substance abuse and depression in minorities remains unexplored, leaving a gap in knowledge concerning the treatment of these comorbid disorders in the fastest growing population in the United States. Cognitive behavior theory posits that specific stressors increase the likelihood of substance abuse. These factors may include structural discrimination experienced by minorities. This quantitative, pretest-posttest archival study examined the effects of a substance abuse treatment program in reducing comorbid depressive symptoms among 317 participants from 3 minority subgroups and a comparison nonminority group enrolled in a court-mandated residential program in Texas. Depression scores were assessed at intake and 30 days later by the Client Evaluation of Self and Treatment-Psychological Functioning. Using gender and age as covariates, a 2 x 2 and a 2 x 3 mixed ANOVA design evaluated changes in depression scores among different racial groups. All participants who completed treatment experienced a significant decline in symptoms associated with depression. By adding to the existing literature regarding the successful treatment of those who participate in a CBT-oriented therapy, this study informs programs seeking successful strategies in helping minorities to enter and complete treatment, which lends itself to positive social change. Further, the efficacy of CBT-oriented therapies across all groups, regardless of race or ethnic identity, provides a unique opportunity for counselors and doctors to develop successful long-term strategies for patients struggling with comorbid substance abuse and depression.

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Background: Cognitive deficits are a core symptom of schizophrenia, severely debilitating and untreated by current medication. However, to date there is limited research focusing on the precise nature of the cognitive disturbances at first episode in ethnic populations. Improved understanding of this will allow improved approaches to therapy. The aim of this study was to investigate cognitive function with a first episode of psychosis South Asian patients. Methods: Twenty South Asian first episode psychosis patients and 15 healthy South Asian matched controls were recruited. All were second generation South Asian people living in the UK. Subjects who took part in the study completed the Positive and Negative Syndrome Scale (patient group), the Wechsler Test of Adult Reading and a battery of neuropsychological assessments to assess specific domains of cognition of relevance to Measurement and Treatment Research to Improve Cognition in Schizophrenia using the Cambridge Neuropsychological Test Automated Battery (CANTAB) (all groups). Results: Results show that first episode patients performed significantly worse than controls across all cognitive domains tested using CANTAB. Significant impairments were found in tests of visual and spatial memory, executive function, working memory, spatial planning and attention. Importantly, a number of cognitive performance indices (visual memory, spatial memory, executive function) were positively correlated with the severity of negative symptoms. Conclusion: We demonstrate that first episode South Asian patients display significant and specific cognitive deficits with evidence to support an association between negative symptoms and certain cognitive domains at first episode in this patient population.