Publications by authors named "Bernadette A Cullen"

23 Publications

  • Page 1 of 1

Symptom severity and medication-assisted treatment for individuals with serious mental illness and a history of heroin use.

Psychiatry Res 2021 Feb 30;296:113671. Epub 2020 Dec 30.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

The study examined associations between medication assisted treatment (MAT) and psychiatric symptom severity, measured by Positive and Negative Symptom Scale (PANSS), among individuals with serious mental illness and a history of heroin use. Of 271 participants, 32% (n=87) reported a history of heroin use and, of those, 14.9% (n=13) reported MAT. Higher scores in PANSS Total, Negative, and Disordered subscales were associated with lower odds, while being on an antipsychotic with higher odds, of receiving MAT. This supports the greater need for clinician attention to different symptom clusters and targeted multidimensional interventions as a way to increase MAT participation.
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http://dx.doi.org/10.1016/j.psychres.2020.113671DOI Listing
February 2021

The relationship between social and environmental factors and symptom severity in the seriously mentally ill population.

Int J Soc Psychiatry 2020 Nov 21:20764020973257. Epub 2020 Nov 21.

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Background: The goal of this article is to investigate the relationship of psychiatric symptom severity with internalised stigma, neighbourhood environment, and social support among individuals with serious mental illness.

Method: Using a longitudinal study design we examined the relationship between psychiatric symptom severity with internalised stigma, neighbourhood environment, and social support among 271 adults with serious mental illness recruited from new admissions to two urban mental health clinics.

Results: After controlling for demographics increased stigma levels predicted greater symptom severity, as measured by the Positive and Negative Syndrome Scale (PANSS) Positive, Negative, and General Psychopathology scales over a 4-year period ( < .05). In adjusted models, individuals who reported living in more disadvantaged neighbourhoods also reported higher PANSS Negative and General scores over time ( < .05). Social support from friends and relatives was not significantly related to PANSS Positive, Negative, or General Psychopathology scores among individuals with serious mental illness.

Conclusions: Individuals with serious mental illness who experience internalised stigma and neighbourhood disadvantage experience greater symptom severity over time. Targeting stigma and housing during treatment could potentially impact symptom severity in this population.
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http://dx.doi.org/10.1177/0020764020973257DOI Listing
November 2020

A Model for Advancing Scale-Up of Complex Interventions for Vulnerable Populations: the ALACRITY Center for Health and Longevity in Mental Illness.

J Gen Intern Med 2021 Feb 31;36(2):500-505. Epub 2020 Aug 31.

Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Many of the most pressing health issues in the USA and worldwide require complex, multi-faceted solutions. Delivery of such solutions is often complicated by the need to reach and engage vulnerable populations facing multiple barriers to care. While the fields of quality improvement and implementation science have made valuable gains in the development and spread of individual strategies to improve evidence-based practice delivery, models for coordinated deployment of numerous strategies to simultaneously implement multiple evidence-based interventions in vulnerable populations are lacking. In this Perspective, we describe a model for this type of comprehensive research-practice translation effort: the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, which is focused on reducing premature mortality in the population with serious mental illness. We describe the Center's conceptual framework, which is built upon an integrated set of quality improvement and implementation science frameworks, provide an overview of the Center's organizational structure and core research-practice translation activities, and discuss our vision for how the Center may evolve over time. Lessons learned from this Center's efforts could inform models to address other critical health issues in vulnerable populations that require multi-component solutions at the policy, system, provider, and patient levels.
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http://dx.doi.org/10.1007/s11606-020-06137-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878664PMC
February 2021

Design and Implementation of a Regional Inpatient Psychiatry Unit for Patients who are Positive for Asymptomatic SARS-CoV-2.

Psychosomatics 2020 Nov - Dec;61(6):662-671. Epub 2020 Jul 2.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.

Background: Patients with psychiatric illnesses are particularly vulnerable to highly contagious, droplet-spread organisms such as SARS-CoV-2. Patients with mental illnesses may not be able to consistently follow up behavioral prescriptions to avoid contagion, and they are frequently found in settings with close contact and inadequate infection control, such as group homes, homeless shelters, residential rehabilitation centers, and correctional facilities. Furthermore, inpatient psychiatry settings are generally designed as communal spaces, with heavy emphasis on group and milieu therapies. As such, inpatient psychiatry services are vulnerable to rampant spread of contagion.

Objective: With this in mind, the authors outline the decision process and ultimate design and implementation of a regional inpatient psychiatry unit for patients infected with asymptomatic SARS-CoV-2 and share key points for consideration in implementing future units elsewhere.

Conclusion: A major takeaway point of the analysis is the particular expertise of trained experts in psychosomatic medicine for treating patients infected with SARS-CoV-2.
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http://dx.doi.org/10.1016/j.psym.2020.06.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330562PMC
November 2020

Clinical outcomes from the texting for relapse prevention (T4RP) in schizophrenia and schizoaffective disorder study.

Psychiatry Res 2020 10 29;292:113346. Epub 2020 Jul 29.

Department of Mental Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Center for Innovative Public Health Research, San Clemente, California, USA.

This 6 month randomized control trial investigated whether a novel text-messaging program impacted targeted clinical outcomes in patients with schizophrenia and schizoaffective disorder (SAD). Forty patients were enrolled and completed baseline, 3-month and 6-month assessments. The intervention group received daily symptom check-in text messages, plus, a medication reminder or, inspirational quote text. The control group had treatment as usual. At 6 months the Positive and Negative Syndrome Scale mean positive score was significantly lower and injectable medication compliance was significantly higher in the intervention group. Recovery scores were significantly higher at 3 months. Results suggest that this program may benefit individuals with schizophrenia/SAD who use text messaging. Further investigation in a larger sample appears warranted.
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http://dx.doi.org/10.1016/j.psychres.2020.113346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530047PMC
October 2020

Adverse childhood experiences (ACEs) and transitions in stages of alcohol involvement among US adults: Progression and regression.

Child Abuse Negl 2020 Sep 16;107:104624. Epub 2020 Jul 16.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health Baltimore, MD, 21205, USA; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health Baltimore, MD, 21205, USA.

Background: Adverse childhood experiences (ACEs) are associated with a number of medical comorbidities. However, there is a paucity of data on the role ACEs play in transitions in stages of alcohol involvement.

Objective: To examine the association between ACEs and transitions in alcohol problems progression and regression between No Problems, Moderate Problems and Severe Problems stages.

Participants And Setting: Data from 14,363 male and 19,774 female participants in Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

Methods: We used latent transition analysis (LTA) with propensity score adjustment to estimate the odds of transitioning across stages of alcohol involvement, between waves, based on the number of types of ACEs experienced. We hypothesized that ACEs would be associated with increased risk of progression and decreased risk of regression.

Results: ACEs were associated with progression to higher alcohol involvement stages, with greatest likelihood of progression from No Problems to Severe Problems for those reporting ≥3 ACEs (males: aOR = 4.78 [CI (1.84-12.44)]; females: aOR = 3.81 [CI (1.69-8.57)]). ACEs were also associated with decreased odds of regression to less problematic alcohol involvement stages, with some distinctive patterns of associations in males and in females.

Conclusions: This study suggests that ACEs impact transitions in alcohol involvement in both males and females, affecting both progression and regression. The association is magnified for those with multiple types of ACE exposures. These results highlight the need for prevention, early identification and intervention to mitigate the risks associated with childhood maltreatment.
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http://dx.doi.org/10.1016/j.chiabu.2020.104624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968748PMC
September 2020

Trichotillomania comorbidity in a sample enriched for familial obsessive-compulsive disorder.

Compr Psychiatry 2019 10 31;94:152123. Epub 2019 Aug 31.

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, United States of America. Electronic address:

Background: This study addresses the strength of associations between trichotillomania (TTM) and other DSM-IV Axis I conditions in a large sample (n = 2606) enriched for familial obsessive-compulsive disorder (OCD), to inform TTM classification.

Methods: We identified participants with TTM in the Johns Hopkins OCD Family Study (153 families) and the OCD Collaborative Genetics Study, a six-site genetic linkage study of OCD (487 families). We used logistic regression (with generalized estimating equations) to assess the strength of associations between TTM and other DSM-IV disorders.

Results: TTM had excess comorbidity with a number of conditions from different DSM-IV chapters, including tic disorders, alcohol dependence, mood disorders, anxiety disorders, impulse-control disorders, and bulimia nervosa. However, association strengths (odds ratios) were highest for kleptomania (6.6), pyromania (5.8), OCD (5.6), skin picking disorder (4.4), bulimia nervosa (3.5), and pathological nail biting (3.4).

Conclusions: TTM is comorbid with a number of psychiatric conditions besides OCD, and it is strongly associated with other conditions involving impaired impulse control. Though DSM-5 includes TTM as an OCD-related disorder, its comorbidity pattern also emphasizes the impulsive, appetitive aspects of this condition that may be relevant to classification.
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http://dx.doi.org/10.1016/j.comppsych.2019.152123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980465PMC
October 2019

Developing Texting for Relapse Prevention: A Scalable mHealth Program for People With Schizophrenia and Schizoaffective Disorder.

J Nerv Ment Dis 2019 10;207(10):854-862

Department of Psychiatry and Behavioral Sciences Johns Hopkins Hospital, Baltimore, Maryland.

Symptom relapse in people with schizophrenia and schizoaffective disorder is common and has a negative impact on the course of illness. Here, we describe the development of Texting for Relapse Prevention, a scalable, cost-effective text messaging relapse prevention program that queries patients' "early warning signs" daily. Results of development focus groups and content advisory teams with 25 patients and 19 providers suggest that patients were enthusiastic about the program and thought that receiving daily messages about their symptoms would help them feel supported. Providers also were positive about the idea but worried that the program might interfere with patient-provider communication if patients thought that the messages were coming from providers. Patients found the content positive and actionable. The program was improved to address this feedback. This iterative development process that included multiple stakeholders ensured that the program is feasible and acceptable to both patients and providers.
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http://dx.doi.org/10.1097/NMD.0000000000001037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189625PMC
October 2019

The Effects of Marijuana Use on Transitions through Stages of Alcohol Involvement for Men and Women in the NESARC I and II.

Subst Use Misuse 2019 12;54(13):2167-2176. Epub 2019 Jul 12.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.

With the changing context of marijuana use, it is critical to identify effects of use. We extend previous work by examining whether marijuana use influences progression and remission through alcohol involvement stages for men and women. Data come from Waves I and II of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC,  = 34,432). We assess the potential influence of marijuana use at Wave 1 on transitions across three latent statuses of alcohol involvement between waves. We apply propensity score weighting to account for shared risk factors. Marijuana use was associated cross-sectionally and longitudinally with alcohol involvement statuses for both sexes. After propensity score adjustment, men with marijuana histories were 3.50 times as likely as men without such histories to transition from no to severe problems across waves relative to staying in the same status ( .001). Women with marijuana histories were 1.74 times as likely as women without such histories to transition from no problems at Wave 1 to moderate problems at Wave 2 ( .030) and 0.13 times as likely as women without such histories to transition from severe problems to no problems ( .006). : Results suggest that marijuana use impacts progression to more serious stages of alcohol involvement for both men and women, as well as hinders remission among women. Findings point to the importance of screening those with marijuana histories for alcohol problems, as well as the need to understand the mechanism of why marijuana use may increase the risk of alcohol problems.
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http://dx.doi.org/10.1080/10826084.2019.1638408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6803069PMC
May 2020

Availability of Assertive Community Treatment in the United States: 2010 to 2016.

Psychiatr Serv 2019 10 12;70(10):948-951. Epub 2019 Jun 12.

Johns Hopkins University School of Medicine (Spivak, Cullen, Mojtabai); Johns Hopkins University Bloomberg School of Public Health (Cullen, Mojtabai); Johns Hopkins Medical Systems (Green, Firth, Sater).

Objective: The study examined change in availability of assertive community treatment (ACT) and associated services over time.

Methods: Change over time in the availability of facilities in the United States offering ACT and its associated services was examined by using 2010 and 2016 data from the National Mental Health Services Survey.

Results: The proportion of facilities that self-reported provision of ACT and its associated services declined between 2010 and 2016 (odds ratio [OR]=0.73, 95% confidence interval [CI]=0.63-0.86, p<0.001). Although a higher proportion of facilities that provided ACT reported offering all the required services in 2016 (OR=1.31, 95% CI=1.04-1.66, p=0.026) compared with 2010, this proportion accounted for less than 20% of the programs. Compared with 2010, in 2016 increases were observed in peer (OR=1.72, 95% CI=1.38-2.13, p<0.001) and co-occurring disorders services (OR=1.23, 95% CI=1.08-1.42, p=0.004) as well as in secondary services, such as tobacco cessation (OR=4.53, 95% CI=3.51-5.84, p<0.001) and telemedicine (OR=2.08, 95% CI=1.67-2.57, p<0.001). Continuous education for staff was required at more facilities with ACT in 2016 compared with 2010.

Conclusions: Although the proportion of facilities with ACT that offer all the required core services has increased in recent years, such programs remain a minority, and the overall number of facilities with ACT has declined.
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http://dx.doi.org/10.1176/appi.ps.201900032DOI Listing
October 2019

Distribution and Correlates of Assertive Community Treatment (ACT) and ACT-Like Programs: Results From the 2015 N-MHSS.

Psychiatr Serv 2019 04 3;70(4):271-278. Epub 2019 Jan 3.

Johns Hopkins University School of Medicine and Johns Hopkins University Bloomberg School of Public Health (Spivak, Mojtabai, Cullen); Johns Hopkins Medical Systems (Green, Firth, Sater).

Objective: The study examined the availability and characteristics of assertive community treatment (ACT) programs across mental health treatment facilities in the United States.

Methods: Prevalence and correlates of facilities that reported offering ACT, broadly defined as intensive community services for serious mental illness provided by multidisciplinary teams in the clients' natural settings and including both ACT and "ACT-like" programs, were examined by using data from the National Mental Health Services Survey. Availability of services essential to the ACT model in these facilities was also examined.

Results: Of the 12,826 surveyed facilities, 13.4% reported offering ACT, with significant variability among states. Of the facilities with ACT, 19.2% reported offering all core ACT services. Few facilities offered peer support, employment, and housing services. Compared with programs at facilities that did not offer all core ACT services, facilities with ACT programs that offered these services had higher odds of being publicly owned (odds ratio [OR]=2.12, 95% confidence interval [CI]=1.64-2.74) and of receiving federal (OR=3.60, CI=2.17-5.98) or grant funding (OR=1.87, CI=1.45-2.41). Facilities with ACT that offered all core services also had higher odds of offering other services important to individuals with serious mental disorders.

Conclusions: Substantial differences existed in availability of ACT and ACT-like programs among states, with evidence of a large unmet need overall, even when a very broad and inclusive definition of ACT was used. Few ACT programs offered all core services. Legislative, administrative, and funding differences may explain some of the variability.
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http://dx.doi.org/10.1176/appi.ps.201700561DOI Listing
April 2019

Altering the Attendance Rate Successfully for New Patients at an Outpatient Mental Health Clinic.

Psychiatr Serv 2018 12 28;69(12):1212-1214. Epub 2018 Aug 28.

Dr. Cullen is with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore, and the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore.

Show rates for psychiatric outpatient appointments are low among new patients, which affects all patients as well as providers and programs. This column describes two initiatives implemented to address this issue in a community psychiatry program: inpatient referrals and self-referrals. Inpatient referrals were scheduled for an orientation group within five days postdischarge, with initial evaluations within two working days. Biweekly walk-in screening clinics were established for community self-referrals, during which patients were screened and scheduled for an initial evaluation within three working days. Both initiatives significantly increased patient show rates and reduced unused scheduled physician time. Relatively simple initiatives can result in improvements in initial evaluation attendance, benefiting all involved.
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http://dx.doi.org/10.1176/appi.ps.201800161DOI Listing
December 2018

Transitions through stages of alcohol involvement: The potential role of mood disorders.

Drug Alcohol Depend 2018 08 10;189:116-124. Epub 2018 Apr 10.

Department of Biostatistical Sciences, Wake Forest School of Medicine, 475 Vine St, Winston-Salem, NC 27101, USA.

Introduction: Although prior clinical and population-based studies have demonstrated comorbidity between mood and alcohol use disorders (AUD), there is a paucity of research assessing whether mood disorders predict transition across stages of alcohol involvement.

Method: Hypothesizing that mood disorders predict transition across sex-specific alcohol involvement stages, we used prospective data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey of US adults, which included male (n = 14,564) and female (n = 20,089) participants surveyed in 2001-2 and re-interviewed in 2004-5. Latent class (LCA) and latent transition analyses (LTA) were used to assess patterns of alcohol involvement in the US and the association of lifetime mood disorders at baseline with transition across stages of alcohol involvement during follow-up.

Results: A three-class model of AUD criteria was identified (No problems, Moderate problems and Severe problems) for both sexes. Positive cross-sectional associations between mood disorder and problem classes of alcohol involvement were found among both sexes, as were positive longitudinal associations. Propensity score adjustment mitigated the associations of baseline mood disorder with progressive transition for both sexes. However, among females, baseline mood disorder was consistently associated with reduction in remission from Severe to Moderate alcohol problems (aOR = 0.30, CI = 0.09-0.99, p = .048) over time.

Discussion: Our study provides evidence that mood disorders impact transition through stages of alcohol involvement and are most strongly associated with hindering remission among females. Findings advance our understanding of these comorbid relationships and have clinical implications for ongoing assessment of drinking patterns among individuals with mood disorders.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.02.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6557161PMC
August 2018

Delays in Seeking General Medical Services and Measurable Abnormalities Among Individuals With Serious Mental Illness.

Psychiatr Serv 2018 04 15;69(4):479-482. Epub 2018 Feb 15.

Dr. Spivak, Dr. Cullen, and Dr. Mojtabai are with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore. Dr. Cullen and Dr. Mojtabai are also with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, where Dr. Eaton and Ms. Rodriguez are affiliated. Dr. Nugent is with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland.

Objective: The study explored the association of delays in seeking general medical care with elevated blood pressure and metabolic abnormalities among individuals with serious mental illness.

Methods: Association of delays in medical care with blood pressure, serum hemoglobin A1c (HbA1C), and lipids was assessed among patients at two inner-city community mental health centers.

Results: Of 271 participants, 62% reported delays in seeking general medical care due to attitudinal and financial barriers. Care delay was associated with abnormalities in measured blood pressure (adjusted odds ratio [AOR]=2.14, p=.029) and HbA1c (AOR=3.18, p=.026). Care delay was not associated with abnormalities in lipid profiles.

Conclusions: This study found that delays in seeking general medical care are common and are associated with clinical markers linked with common medical conditions. The results may help to explain the elevated morbidity and mortality associated with serious mental illness.
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http://dx.doi.org/10.1176/appi.ps.201700327DOI Listing
April 2018

Exposure to Direct-to-Consumer Pharmaceutical Advertising and Medication Nonadherence Among Patients With Serious Mental Illness.

Psychiatr Serv 2017 Dec 15;68(12):1299-1302. Epub 2017 Sep 15.

Ms. Green, Dr. Mojtabai, Dr. Cullen, Ms. Mitchell, and Dr. Spivak are with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore. Dr. Mojtabai and Dr. Cullen are also with the Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Ms. Spivak is with The Samaritan Women, Baltimore.

Objective: This study explored the association of exposure to direct-to-consumer advertising (DTCA) with medication nonadherence among individuals with serious mental disorders.

Methods: Results of an anonymous survey administered at an inner-city mental health clinic were examined by using logistic regression. Nonadherence was defined as not taking prescribed medications for at least two out of seven days.

Results: Of 246 respondents, 48% reported DTCA exposure and 43% reported nonadherence. Sixty-one percent of those exposed to DTCA reported nonadherence, compared with 26% of those not exposed (adjusted odds ratio=4.96, 95% confidence interval=2.64-9.33, p<.001). Among those exposed to advertisements and reporting nonadherence, 59% reported changing medication-taking behaviors or stopping prescribed medications because of side effect information in advertisements. Only a minority communicated with providers before becoming nonadherent.

Conclusions: This study found an association between self-report of DTCA exposure and self-reported nonadherence. These results support further research on DTCA as a possible risk factor for nonadherence.
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http://dx.doi.org/10.1176/appi.ps.201700035DOI Listing
December 2017

Interrater reliability of the modified Monitoring of Side Effects Scale for assessment of adverse effects of psychiatric medication in clinical and research settings.

J Clin Psychopharmacol 2015 Jun;35(3):324-8

From the *Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine; †Community General Psychiatry Division, Johns Hopkins Bayview Medical Center; ‡Department of Medical Informatics, Kennedy Krieger Institute; §Department of Mental Health, Johns Hopkins Bloomberg School of Public Health; ∥Laboratory for Neurocognitive Imaging Research, Kennedy Krieger Institute, Baltimore, MD; ¶The Lewin Group, Falls Church VA; #School of Nursing, Johns Hopkins University; **Francis King Carey School of Law, University of Maryland; and ††Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.

The assessment of adverse effects of psychiatric medications is important in clinical and research settings because they are often associated with medication discontinuation, symptom exacerbation, and reduced quality of life. Currently available assessment tools are either limited with regard to the number and variety of included adverse effects or are not practical for use in most clinical or research settings owing to specialized rater training required and administration length. This report describes a modification of the Monitoring of Side Effects Scale (MOSES), an established adverse effect rating scale, by adding severity anchors to improve its reliability and ease of use. Interrater reliability was good for 7 of the 8 bodily adverse effects assessed, with intraclass correlation coefficients ranging from 0.76 to 0.91 in a sample of patients with severe mental illness. This modified version of the Monitoring of Side Effects Scale holds promise as a useful tool for assessing medication adverse effects in clinical and research settings.
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http://dx.doi.org/10.1097/JCP.0000000000000311DOI Listing
June 2015

Gender and race/ethnicity differences for initiation of alcohol-related service use among persons with alcohol dependence.

Drug Alcohol Depend 2014 Jul 20;140:48-55. Epub 2014 Mar 20.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Prior studies on treatment for alcohol-related problems have yielded mixed results with respect to gender and race/ethnicity disparities. Additionally, little is known about gender and racial differences in time to first alcohol-related service contact amongst persons with alcohol dependence. This study explored gender and race/ethnicity differences for first alcohol-related service utilization in a population-based sample.

Methods: Primary analyses were restricted to Blacks, Whites and Hispanics, ages 18-44, with lifetime alcohol dependence (n=3311) in Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions. We compared time to service use among men and women within and across race/ethnicity strata using multivariable Cox proportional hazard methods.

Results: In the sample of individuals age <45 with alcohol dependence, only 19.5% reported alcohol-related service use. Overall, women were less likely than men to receive alcohol-related services in their lifetime. However, women who did receive treatment were younger at first service utilization and had a shorter interval between drinking onset and service use than men. Gender differences were consistent across racial/ethnic groups but only statistically significant for Whites. There were no appreciable race/ethnicity differences in hazard ratios for alcohol-related service use or time from drinking initiation to first service contact. Results of sensitivity analyses for persons ≥45 years old are discussed.

Conclusions: There are important gender differences in receipt of and time from drinking initiation to service utilization among persons with alcohol dependence. Increased recognition of these differences may promote investigation of factors underlying differences and identification of barriers to services.
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http://dx.doi.org/10.1016/j.drugalcdep.2014.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079072PMC
July 2014

Use of mobile phones, computers and internet among clients of an inner-city community psychiatric clinic.

J Psychiatr Pract 2014 03;20(2):94-103

CARRAS, FURR-HOLDEN, and EATON: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; MOJTABAI and CULLEN: Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins University School of Medicine.

Objective: Recent years have witnessed an expansion of Internet- and mobile-phone-based interventions for health promotion, yet few studies have focused on the use of technology by individuals with mental illness. This study examined the extent to which patients at an inner-city community psychiatry clinic had access to information and communications technology (ICT) and how they used those resources.

Methods: Patients of an outpatient, inner-city community psychiatry program (N=189) completed a survey that included questions about demographics and ICT use which were adapted from an existing local population-based health survey (community sample, N=968). Frequencies of ICT use were assessed for the clinic sample and questions common to both the surveys completed by the clinic and community samples were compared using logistic regression.

Results: Among clinic cases, 105 (55.6%) reported owning or using a computer, 162 (85.7%) reported owning or using a mobile phone, and 112 (59.3%) reportedf using the Internet. Among those who used mobile phones, the majority reported using them daily; 42% of those who used the Internet reported using it several times per day. Differences in frequency of Internet use between samples were not significant, but clinic participants used the Internet more intensively to email, instant message, access health information, and use social media sites.

Conclusions: A majority of patients in this community psychiatry clinic sample use ICT. Greater access to and use of the Internet by those with mental illness has important implications for the feasibility and impact of technology-based interventions.
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http://dx.doi.org/10.1097/01.pra.0000445244.08307.84DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699472PMC
March 2014

Comorbid Alcohol Dependence and Anxiety Disorders: A National Survey.

J Dual Diagn 2013 ;9(4)

Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health.

Objective: The goal of this study was to describe onset of comorbid anxiety disorders and alcohol dependence based on a large national survey of the US adult population, and to explore and describe these patterns by gender.

Methods: Using Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we compared age of onset and temporal ordering of onset of comorbid alcohol dependence and anxiety disorders. Analyses were stratified by gender. Mean ages of onset were calculated, and Wald F-tests were used to assess differences in ages of onset, accounting for the complex survey design of the NESARC. Weighted estimates were used, adjusted to be representative of the US population on various sociodemographic variables based on the 2000 Decennial Census.

Results: Differences in temporal ordering were observed, but varied by disorder combination. The majority (65%) had a primary (earliest onset) anxiety disorder, while the remaining 35% had a primary alcohol dependence diagnosis. Age of onset for some individuals with an anxiety disorder comorbid with alcohol dependence was earlier than for those with an anxiety disorder alone. Among individuals with comorbid social phobia and alcohol dependence, and comorbid specific phobia and alcohol dependence, it was more common to experience anxiety disorder as the primary diagnosis. Conversely, among individuals with comorbid panic disorder and alcohol dependence, and generalized anxiety disorder and alcohol dependence, it was more common to experience alcohol dependence as the primary diagnosis. Women were more likely to report having multiple comorbid anxiety disorders. No gender differences were found in terms of age of onset or temporal ordering of onset of comorbid disorders.

Conclusions: Subsets of individuals with comorbid disorders exist, some whose primary diagnosis is alcohol dependence, and a majority of individuals whose primary diagnosis is an anxiety disorder with significant variability in age and temporal ordering of onset and few gender differences. Improved understanding of patterns of comorbidity and lag time between the onsets of specific disorders may enable us to identify potential groups for early intervention.
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http://dx.doi.org/10.1080/15504263.2013.835164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817611PMC
January 2013

Partitioning the heritability of Tourette syndrome and obsessive compulsive disorder reveals differences in genetic architecture.

PLoS Genet 2013 Oct 24;9(10):e1003864. Epub 2013 Oct 24.

Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, United States of America.

The direct estimation of heritability from genome-wide common variant data as implemented in the program Genome-wide Complex Trait Analysis (GCTA) has provided a means to quantify heritability attributable to all interrogated variants. We have quantified the variance in liability to disease explained by all SNPs for two phenotypically-related neurobehavioral disorders, obsessive-compulsive disorder (OCD) and Tourette Syndrome (TS), using GCTA. Our analysis yielded a heritability point estimate of 0.58 (se = 0.09, p = 5.64e-12) for TS, and 0.37 (se = 0.07, p = 1.5e-07) for OCD. In addition, we conducted multiple genomic partitioning analyses to identify genomic elements that concentrate this heritability. We examined genomic architectures of TS and OCD by chromosome, MAF bin, and functional annotations. In addition, we assessed heritability for early onset and adult onset OCD. Among other notable results, we found that SNPs with a minor allele frequency of less than 5% accounted for 21% of the TS heritability and 0% of the OCD heritability. Additionally, we identified a significant contribution to TS and OCD heritability by variants significantly associated with gene expression in two regions of the brain (parietal cortex and cerebellum) for which we had available expression quantitative trait loci (eQTLs). Finally we analyzed the genetic correlation between TS and OCD, revealing a genetic correlation of 0.41 (se = 0.15, p = 0.002). These results are very close to previous heritability estimates for TS and OCD based on twin and family studies, suggesting that very little, if any, heritability is truly missing (i.e., unassayed) from TS and OCD GWAS studies of common variation. The results also indicate that there is some genetic overlap between these two phenotypically-related neuropsychiatric disorders, but suggest that the two disorders have distinct genetic architectures.
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http://dx.doi.org/10.1371/journal.pgen.1003864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812053PMC
October 2013

Association of comorbid generalized anxiety disorder and alcohol use disorder symptoms with health-related quality of life: results from the National Epidemiological Survey on Alcohol and Related Conditions.

J Addict Med 2013 Nov-Dec;7(6):394-400

From the Department of Psychiatry and Behavioral Sciences (BAC, RM, RMC), Johns Hopkins School of Medicine, Baltimore, MD; Department of Mental Health (BAC, LNLF, CLS, RM, LRP, RMC), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Department of Family and Community Health (CLS), University of Maryland Baltimore School of Nursing, Baltimore, MD; Department of Behavioral and Community Health (KMG), University of Maryland School of Public Health, College Park, MD; Division of General Internal Medicine (AAHA), Johns Hopkins School of Medicine, Baltimore, MD; and Department of Epidemiology (RMC), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Background: Although prior studies have documented the co-occurrence of generalized anxiety disorder (GAD) and alcohol use disorder (AUD) disorder, there is a paucity of research assessing the patterns of alcohol involvement among individuals with GAD symptoms. This study investigated subtypes, or classes, of comorbid AUD and GAD symptoms, and assessed the association of class membership with health-related quality of life.

Methods: Using data from the Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions, a latent class analysis was performed on the subset of individuals who were current drinkers and had reported ever experiencing a 6-month episode of feeling tense, nervous, or worried most of the time. We examined the association of these latent classes with physical and mental health-related quality of life measured by the Short Form-12, version 2.

Results: Latent class analysis identified a 5-class model of AUD and GAD symptoms. A significant graded relationship was observed between the ordered classes and severity of impairment on the mental health scale of the Short Form-12, version 2, but no significant relationship was found with the physical health scale.

Conclusions: Mental, but not physical, health-related quality of life in this population is associated with both the number and pattern of comorbid GAD and AUD symptoms.
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http://dx.doi.org/10.1097/ADM.0b013e31829faa1cDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3839307PMC
April 2014

Rationale, design and baseline data for the Activating Consumers to Exercise through Peer Support (ACE trial): A randomized controlled trial to increase fitness among adults with mental illness.

Ment Health Phys Act 2012 Dec 31;5(2):166-174. Epub 2012 May 31.

Department of Kinesiology, Towson University, Towson, Maryland, USA ; Department of Medicine, Johns Hopkins School of Medicine, Baltimore Maryland, USA.

Background: The benefits of regular physical activity are particularly salient to persons with serious mental illness (SMI) who have increased prevalence of obesity, diabetes, and earlier mortality from cardiovascular disease.

Methods: The Activating Consumers to Exercise through Peer Support (ACE) trial will examine the effectiveness of peer support on adherence to a 4-month pilot exercise program for adults with SMI. Design, rationale and baseline data are reported. Baseline measures included: graded treadmill test; six-minute walk; height, weight and blood pressure; body composition; fasting blood; and self-reported psychiatric symptoms. Fitness levels were compared with national data and relationships among fitness parameters, psychological factors and cardiovascular disease risk factors were examined.

Results: There were 93 participants and 18 peer leaders recruited from community psychiatry programs with an average age of 47 years (SD 10). There were no differences in demographics (76% female, 72% African American) or mental health symptoms between participants and peer leaders. Ninety-five percent of the sample had below average fitness levels for their age and sex with average MET levels of 5.9(SD 2.2) for participants and 6.2(SD 2.3) for peer leaders. Fitness evaluated during the treadmill test and the six-minute-walk were associated (r = 0.36, p<.001). Lower MET levels were associated with a higher BMI (r = -0.35, p<.001) and percent body fat (r = -0.36, p <.001).

Conclusion: The uniformly low baseline cardiovascular fitness and the association of fitness with BMI and adiposity underscore the importance of suitably tailored programs to increase physical activity among adults with SMI.
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http://dx.doi.org/10.1016/j.mhpa.2012.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587110PMC
December 2012

Guideline-concordant antipsychotic use and mortality in schizophrenia.

Schizophr Bull 2013 Sep 30;39(5):1159-68. Epub 2012 Oct 30.

Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective: To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality.

Methods: We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality.

Results: Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57-0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58-0.98) and 0.84 (95% CI 0.58-1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10-3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55-0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93-0.98).

Conclusions: Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.
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http://dx.doi.org/10.1093/schbul/sbs097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756776PMC
September 2013