Schneeberger 2014 Use of Psychotropic Medication ...

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Journal of Trauma & Dissociation, 15:494–511, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2014.903550

Use of Psychotropic Medication Groups in People with Severe Mental Illness and Stressful Childhood Experiences ANDRES R. SCHNEEBERGER, MD Psychiatric Outpatient Department, Psychiatric Services Grisons, St. Moritz, Switzerland; Department of Psychiatry, Albert Einstein College of Medicine, Bronx, New York, USA; and Department of Psychiatry, University Hospital, Basel, Switzerland

KRISTINA MUENZENMAIER, MD Department of Psychiatry, Bronx Psychiatric Center, Bronx, New York, USA; and Department of Psychiatry, Albert Einstein College of Medicine, Bronx, New York, USA

DOROTHY CASTILLE, PhD New York State Psychiatric Institute, Columbia University, New York, New York, USA

JOSEPH BATTAGLIA, MD Department of Psychiatry, Bronx Psychiatric Center, Bronx, New York, USA; and Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York, USA

BRUCE LINK, PhD New York State Psychiatric Institute, Columbia University, New York, New York, USA; and Department of Epidemiology, Mailman School of Public Health, New York, New York, USA

Stressful childhood experiences (SCE) are associated with a variety of health and social problems. In people with severe mental illness (SMI) traumatic childhood experiences have been linked to more severe and treatment refractory forms of psychiatric symptoms, including psychotic symptoms. This study evaluates the use of psychotropic medication groups in a population of people with SMI and SCE, testing the association between SCE Received 29 September 2013; accepted 25 February 2014. Address correspondence to Andres R. Schneeberger, MD, Department of Psychiatry, University Hospital, Basel, Plazza Paracelsus 2, 7500 St. Moritz, Switzerland. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www. tandfonline.com/wjtd. 494


Journal of Trauma & Dissociation, 15:494–511, 2014

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and prescription medication in an SMI population. A sample of 183 participants with SMI was divided into 2 exposure groups: high SCE (4 to 7 categories of SCE) and low SCE (0 to 3 categories of SCE). Both groups were compared in regard to prescribed dosing of psychotropic medications (antipsychotics, mood stabilizers, antidepressants, and anxiolytics/hypnotics). Participants who endorsed high SCE received higher doses of antipsychotic medications and mood stabilizers than those with low exposure. The results demonstrate that people with higher SCE categories received a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers. KEYWORDS childhood abuse, childhood trauma, child sexual abuse, complex trauma, schizophrenia, severe mental illness, treatment, psychopharmacology

INTRODUCTION Childhood adversities are associated with a vast array of health and social problems both in the general population and in people with severe mental illness (SMI; Felitti et al., 1998; Rosenberg, Lu, Mueser, Jankowski, & Cournos, 2007). An increasing literature supports a high prevalence of childhood adversities in people diagnosed with SMI (Read, Fink, Rudegeair, Felitti, & Whitfield, 2008; Rosenberg et al., 2007). Although studies have connected the prevalence of multiple types of adverse childhood experiences (ACE) and the effects of individual abuse variables, less is known about the effects of cumulative trauma (Muenzenmaier et al., in press). The term stressful childhood experiences (SCE) refers to a range of life events such as childhood sexual abuse, physical abuse, and emotional abuse, as well as items of household dysfunction, including substance abuse of the caregiver, mental illness of the caregiver, and witnessing the arrest of a household member (Muenzenmaier et al., in press). In a study with a sample of people enrolled in the Kaiser Permanente San Diego Health Appraisal Study, Felitti et al. (1998) found associations among childhood abuse, adult health risk behaviors, and disease and postulated that maladaptive behavior is an unsuccessful attempt to cope with the social, emotional, and cognitive impairments caused by ACE. Newer studies (Spauwen, Krabbendam, Lieb, Wittchen, & van Os, 2006; Varese et al., 2012) have suggested that childhood adversity may present a risk factor for the development of psychotic symptoms (Schafer & Fisher, 2011). Population-based studies have confirmed these findings, showing that children who experienced maltreatment were more likely to report psychotic symptoms than those exposed to accidents (Arseneault et al., 2011).


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Bebbington et al. (2004) showed that psychotic symptoms are related in a dose–response fashion to the intensity of abuse. In addition, comorbid presentations of affective and psychotic symptoms are suggested to be related to complex forms of trauma-related symptoms. Studies have also shown a significant overlap between dissociative disorders and childhood abuse (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006) as well as dissociation and psychotic symptoms in people with SCE (Moskowitz & Corstens, 2007). Furthermore, trauma symptoms can present as part of a complex phenomenon on a psychotic/dissociative spectrum (Schafer, Ross, & Read, 2008). Some researchers propose that positive symptoms of schizophrenia (hallucinations, delusions, thought disorders) actually represent reexperiencing (Read, Agar, Argyle, & Aderhold, 2003), paranoia (Sautter et al., 1999), or dissociative symptoms directly related to earlier traumatic experiences (Ross, 2006). The traumagenic neurodevelopmental model of schizophrenia suggests a strong relationship between childhood abuse and hallucinations (Read, Perry, Moskowitz, & Connolly, 2001). SCE also appears to be connected to a variety of other psychiatric symptoms. In health insurance population samples, Anda and colleagues (2006) demonstrated associations with affective, anxiety, and panic symptoms; suicide attempts; and sleep disturbances. SCE have also been linked to posttraumatic stress disorder (PTSD) symptoms (Kessler, Chiu, Demler, Merikangas, & Walters, 2005), substance abuse (Garno, Goldberg, Ramirez, & Ritzler, 2005), and cognitive deficits (Majer, Nater, Lin, Capuron, & Reeves, 2010). Conducting a secondary analysis of the National Comorbidity Survey–Replication, Putnam, Harris, and Putnam (2013) examined additive and multiplicative synergistic interactions of childhood adversities on complex adult psychopathology. In their analyses, increased counts of types of childhood adversities were associated with an increase in the number of separate Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ), diagnoses, the number of different DSM–IV disorder categories, and the coexistence of internalizing disorders (depression and anxiety disorders) and externalizing disorders (attention and conduct disorders). The pharmacological treatment of PTSD has been studied extensively (Friedman & Davidson, 2010); however, evidence for the use of psychotropic medication on people who have experienced more complex forms of trauma is sparse (Opler, Grennan, & Ford, 2009). Given the absence of a formal diagnosis for complex forms of trauma caused, for example, by SCE, Opler et al. (2009) suggested addressing existing psychiatric diagnoses that include symptoms similar to complex forms of trauma. People with borderline personality disorder and complex PTSD can benefit from antidepressant medication addressing symptoms of affective instability and anger as well as from antipsychotic medication that helps to stabilize relationships and improve psychosocial functioning (Nose, Cipriani, Biancosino, Grassi, & Barbui, 2006). Patients with dissociative disorders have been found to benefit



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from selective serotonin reuptake inhibitors for dysphoria, irritability, panic, and intrusive reexperiencing; in this population, antipsychotics help with thought disorganization, agitation, and intrusive reexperiencing (Chu, 2005). Mood stabilizers show improvements for extreme emotion states and lability (Opler et al., 2009). Duffy and Malloy (1994) reported that there is some evidence for the use of the anxiolytic buspirone for the treatment of reexperiencing, avoidance, and intrusions as well as alpha-1 receptor agonists to target hyperarousal and intrusive reexperiencing (Friedman & Davidson, 2010). Opler et al. (2009) suggested that, based on a study with combat veterans with chronic PTSD (Akuchekian & Amanat, 2004), topiramate may be beneficial in the treatment of complex forms of trauma. Another mood stabilizer that has shown some efficacy in the treatment of chronic forms of trauma is valproic acid (Fesler, 1991). The use of antipsychotic medication such as risperidone has proven to be effective in the treatment of chronic PTSD (Bartzokis, Lu, Turner, Mintz, & Saunders, 2005). Reich, Winternitz, Hennen, Watts, and Stanculescu (2004) showed low-dose risperidone to be more effective than placebo in women with histories of SCE. Also, quetiapine is effective in reducing signs related to complex forms of trauma, such as dissociative symptoms and aggression (Friedman & Davidson, 2010). The ACE study (Felitti et al., 1998) prospectively analyzed the prescription refill patterns of members of the Kaiser health care plan, from which the ACE study population was taken. The authors reported that the use of psychotropic medication displayed a strong, graded association with childhood trauma (Anda et al., 2007). As the ACE score increased, the rates of prescribed psychotropic medication increased. To our knowledge there are no studies focusing on the different psychotropic medication groups in a population of people with SMI and histories of SCE and possible differences in regard to dosing. This study addresses the use of psychotropic medication groups in the SMI population with persons who have experienced SCE. Considering the aforementioned literature and the described relationship between SCE and diverse psychotic symptoms as well as problems with impulse control and emotional lability, we hypothesize that people with SMI and SCE will require a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers. If the symptoms are caused or worsened by SCE, the literature suggests that medication will not exhibit the same beneficial effects and treating physicians will therefore increase the dosing.

METHODS The New York State Office of Mental Health commissioned a project to evaluate the effects of mandated treatment in people with SMI (Link, Castille, & Stuber, 2008). The participants, who were within 3 months following


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discharge from psychiatric inpatient treatment, were recruited from seven different psychiatric outpatient clinics in New York City. Eligible participants who met inclusion criteria and were interested in participating were screened by a clinician and assessed for capacity to provide informed consent. Respondents who qualified were included in the study and compensated financially for their time. Additional information was gained from clinical charts—specifically, information about medications, dosing, schedule, and administration was derived from chart reviews. The institutional review boards of the different study sites as well as the New York State Office of Mental Health and New York State Psychiatric Institute approved the procedure.

Study Sample The sample included 183 participants (111 men and 72 women) ages 18 to 65 years. They all had a history of SMI and were able to give informed consent. Sociodemographic information about the study population can be found in Phelan et al. (2010). Medical charts showed the following diagnostic distribution in the examined population: schizophrenia (39.9%, n = 73), schizoaffective disorder (32.2%, n = 59), bipolar disorder (18.6%, n = 34), major depressive disorder (7.1%, n = 13), and other (2.2%, n = 4). There was no documentation of PTSD, complex PTSD, or dissociative identity disorder (DID) in any of the charts. With the exception of race the sample reflected the patient population found in state psychiatric clinics in Queens and the Bronx, New York (Castille, Muenzenmaier, & Link, 2011).

Measures Interviewers, professionals experienced in interviewing people with SMI, were extensively trained and monitored for adherence to study procedures. The interview included measures of demographics, psychiatric history, medical history, prescribed medication, and attitudes toward medication and treatment. Interviews were conducted between January 2003 and January 2006. The Structured Clinical Interviews for DSM (First & Gibbon, 2004) and a section of the Psychiatric Research Interview for Substance and Mental Disorders (Hasin et al., 1996) were used to assess psychotic symptoms. For the assessment of physical and sexual abuse the Histories of Physical and Sexual Abuse Questionnaire (Meyer, Muenzenmaier, Cancienne, & Struening, 1996) was administered. Examples of the questions used to assess SCE, including items of household dysfunction, are listed in Schneeberger, Muenzenmaier, Battaglia, Castille, and Link (2012). The cumulative trauma



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score SCE was created by scoring the presence of each category of exposure, regardless of the frequency, duration, or types of exposures to a type of event, as described by Schneeberger et al. The aforementioned categories of childhood abuse and household dysfunction were included in this score and summed, reaching a maximum score of seven. Following Felitti et al. (1998), who initially described seven categories of ACE, two subgroups were created using four or more adverse childhood events as high exposure to analyze odds ratios for the presence of disease. To confirm this cut point, we analyzed the area under the receiver operating characteristic curve for the SCE score predicting the presence of psychotic symptoms (area under the curve = 0.716; p < .001). A cutoff point of four showed high specificity (91.3%), avoiding false positive results. Medical charts review yielded the currently prescribed medications, the dose, the means of administration, and the medication schedule. The following categories of psychotropic medications were analyzed: antipsychotics, mood stabilizers, antidepressants, and anxiolytics and hypnotics (see Table 1 for substances included in each category as well as dosing). Reference to existing literature permitted us to calculate the equivalence dosing for comparing different medications. For the comparison of antipsychotic medications, Gardner, Murphy, O’Donnell, Centorrino, and Baldessarini (2010) described a systematically acquired expert consensus on antipsychotic equivalence dosing based on information from a questionnaire-based survey of research and clinical experts’ opinion, using olanzapine as reference value. To facilitate the dosing comparison of mood stabilizers, we based the dosing on the potency ratio of each agent as described by Centorrino et al. (2006), who used lithium carbonate as a reference value and determined the median manufacturer’s recommended daily dose. We compared antidepressants using equivalent adequacy values proposed by Weilburg, O’Leary, Meigs, Hennen, and Stafford (2003). The authors described adequate treatment with antidepressants as a prescription of the lowest effective dosage of an antidepressant for a time period of at least 90 days. We based the equivalence dosing for benzodiazepines and other anxiolytics or hypnotics on Ashton (1994), who used 1 mg lorazepam as the reference value in a clinical sample (Ashton, 1987). The effects from these results were controlled with the equivalent daily doses of benzodiazepines proposed by Saunders and Yang (2002), who based their reference system on 5 mg diazepam. We used the Rating of Medication Influences (ROMI) scale in schizophrenia to measure adherence with medication treatment (Weiden et al., 1994). The ROMI comprises two subscales, with items targeting adherence and nonadherence. The interrater reliability of this instrument varies for adherence items (κ = 0.75–1.0) and for nonadherence items (κ = 0.60 – 1.0). Weiden et al. (1994) found moderate internal consistency (Cronbach’s α = .57) for the ROMI.

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23 25.7 13.1 1.6 3.3 8.2 18 8.7 1.6 31.2 6.6 1.1 4.4 3.3 1.6 1.1 4.9 4.4 5.5 2.2 2.7 4.4 3.3 3.3 2.7 2.2 2.2

33 16 3 57 12 2 8 6 3 2 9 8 10 4 5 8 6 6 5 4 4

%

42 47 24 3 6 15

Total n

10 1.5 1.5

30 28.1 145 108 24.1 125 131.3 18.3 81.3

835.3 256.3 150 537 58.1 525

6.7 2 16.3

2.8 18.4 285.9 90 20 226.7

mg

20 1 3

30 28.1 145 43.2 32.2 33.3 17.5 36.6 5.4

584.7 256.3 175.5 418.9 222 525

13.4 3.3 10.9

9.3 18.4 7.7 11.3 13.4 11.3

Equivalencea

1 1 1

1 6 3 5 2 2 6 3 2

32 12 2 3 2 2

23 7 2

29 25 13 2 2 10

n

1 1 1

1 5.8 2.9 4.9 1.9 1.9 5.8 2.9 1.9

31.1 11.7 1.9 2.9 1.9 1.9

22.3 6.8 1.9

28.2 24.3 12.6 1.9 1.9 9.7

%

mg

10 1 0.5

20 26.2 150 86 22.5 100 137.5 13.3 75

635.9 512.5 300 434 35 450

4.48 1.82 12.5

2.7 17.2 226.2 80 20 277.5

Low SCE (0–3)

4 3 3

1 3 5 5 2 3 2 3 4

25 0 0 5 4 1

10 9 1

13 22 11 1 4 5

n

5.5 4.1 4.1

1.4 4.1 6.8 6.8 2.7 4.1 2.7 4.1 5.5

34.2 0 0 6.8 5.5 1.4

13.7 12.3 1.4

17.8 30.1 15.1 1.4 5.5 6.8

%

8.9 2.1 20

2.9 19.5 345.5 100 20 125

mg

10 2 2.5

40 30 140 130 27.5 150 125 23.3 87.5

1, 035 0 0 640 81.3 600

High SCE (4–7)

Notes: Total n = 176; missing data = 7. Low SCE: score 0–3, n = 103. High SCE: score 4–7, n = 73. SCE = stressful childhood experiences. a Calculated equivalence dosing.

Atypical antipsychotics Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Clozapine Typical antipsychotics Haloperidol Fluphenazine Thiothixene Mood stabilizers Valproic acid Lithium Carbamazepine Gabapentin Topiramate Oxcarbazepine Antidepressants Citalopram Paroxetine Fluoxetine Sertraline Mirtazapine Venlafaxine Bupropion Escitalopram Trazodone Anxiolytics/hypnotics Zolpidem Lorazepam Clonazepam

Medication

TABLE 1 Psychotropic Medication and SCE



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Statistical Analyses We used the statistics software IBM SPSS Statistics Version 20.0 to analyze the data. We used logistic regression to assess the relationship of the SCE score to age, gender, ethnicity/race, place of origin, religion, sexual orientation, socioeconomic status, and involuntary outpatient commitment and to control for the potential confounding effects on medications, dosing, method of application, medication schedules, adherence, nonadherence, and attitudes toward medications. The main analysis focused on oral medication. All statistical inferences were based on a significance level of at least α = .05. Variables were measured on nominal or ordinal scales and were tested with chi-square, odds ratio, and Student’s t tests.

RESULTS Prevalence of ACE Analysis of the categories of self-reported childhood abuse shows that 48.6% (n = 76) of the examined population endorses a history of emotional abuse, 73.2% (n = 115) experienced physical abuse in their childhood, and 24.6% (n = 39) of all participants were victims of sexual abuse as children. Categories examining household dysfunction, such as substance abuse of the caregiver, are endorsed by 47.0% (n = 74), and 29% (n = 45) had a caregiver with mental illness. Of the participants, 37.2% (n = 58) witnessed violent behavior in their family, and 36.4% (n = 57) report someone in their immediate family having been arrested.

Test of Central Hypothesis—Psychotropic Medications The analysis of the psychotropic prescription medication in relation to the prevalence of SCE, categorized into a low and a high SCE subgroup, reveals that the dosing of the medications varies significantly between the two subgroups. As illustrated in Figure 1, the atypical antipsychotics category shows a significantly higher equivalent dosing in the group with high scores of SCE (olanzapine equivalent dosing: 13.1 mg) versus the group with low SCE scores (olanzapine equivalent dosing: 10.4 mg; p < .05). Moreover, 77.8% (n = 137) of the whole sample receives treatment with an atypical antipsychotic medication. As described in Table 1, the most commonly prescribed atypical antipsychotic is olanzapine (n = 47, 25.7%; see Table 1). Typical antipsychotics are prescribed to 29.5% (n = 52) of the entire sample. The most frequently prescribed antipsychotic is haloperidol (n = 33, 18.0%; see Table 1). The compound comparison of the typical antipsychotic dosing reveals a significantly higher dosing (olanzapine equivalent dosing: 11.1 mg)



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FIGURE 1 Stressful childhood experiences (SCE) and mean equivalence dose. Total n = 176; missing data = 7. Low SCE: score 0–3, n = 103. High SCE: score 4–7, n = 73.



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for the high SCE subgroup versus an olanzapine equivalent dosing of 7.6 mg (p < .05) for the low SCE subgroup (see Figure 1). The medication category composed of mood stabilizers follows the same pattern, showing that people with high SCE receive higher doses of the same medication than people with low SCE (see Figure 1). Of the entire sample, 40.3% (n = 71) receive a mood stabilizer as part of their treatment plan. The average dose corresponds to a lithium carbonate equivalent of 641.2 mg for the group with high SCE being significantly higher than the average dose in the low SCE group (lithium carbonate equivalent: 439.2 mg; p < .01; see Figure 1). Valproic acid is the substance within this category prescribed most frequently (n = 57, 31.2%; see Table 1). Within the examined population, 33.0% (n = 58) are prescribed an antidepressant medication as part of their regimen. The high SCE group has a mean equivalence dosing of 52.7 mg (reference: fluoxetine) and the low SCE group has a fluoxetine equivalence value of 37.1 mg, a nonsignificant trend (p < .1; see Figure 1). Anxiolytic medications as well as hypnotic medications show a nonsignificant difference between the two subgroups (p < .5; see Figure 1). Among study participants, the average number of psychotropic medications prescribed is 2.9 (SD = 1.44–4.36; men: M = 3.0, SD = 1.52–4.48; women: M = 2.7, SD = 1.29–4.11, ns). There is no significant difference between people with high or low SCE in the number of prescribed medications. The medication schedule frequency varies between once daily to three times a day regarding the administration of oral psychotropic medication. The average frequency of medication intake in this population is 1.29 (SD = 1.02–1.56), meaning that most participants take their medication once or twice a day. There is no significant difference between the analyzed subgroups (low SCE: M = 1.28, SD = 1.0–1.56; high SCE: M = 1.29, SD = 1.03–1.55, ns). A number of participants (17) receive intramuscular depot medication (males: n = 16, females: n = 1). The results regarding oral medications remained significant after we controlled for intramuscular depot medication.

DISCUSSION Prevalence of SCE This study shows high rates of SCE in this examined population of people with SMI. The results are in line with other studies (Mueser, Rosenberg, Goodman, & Trumbetta, 2002; Rosenberg et al., 2007) and show that not only traumatic experiences but also experiences of household dysfunction are affecting this population. Exposure to cumulative traumatic experiences puts the individual at risk for maladaptive coping strategies and complex trauma symptoms (Ford & Courtois, 2009; Putnam et al., 2013). The high


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prevalence of SCE found in the examined sample endangers the participants, specifically for developing more psychotic symptoms (Spauwen et al., 2006) and affective dysregulation (Read & Ross, 2003). Considering the lack of chart diagnosis regarding PTSD, complex PTSD, and DID, there is the possibility that symptoms classified as psychotic might indeed be misdiagnosed symptoms of these complex trauma phenomena (Muenzenmaier, Spei, & Gross, 2010). Read et al. (2001) proposed a strong relationship between childhood abuse and hallucinations. Sautter et al. (1999) found in a sample of combat veterans diagnosed with PTSD and schizophrenia high levels of paranoia due to extreme hypervigilance. Based on the trauma dissociation model of psychosis, Moskowitz and Corstens (2007) contended that hearing voices should be conceptualized as a dissociative experience that under certain circumstances can be pathologic. Hearing voices may appear in the context of a psychotic disorder but should not be considered pathognomonic of a psychotic disorder.

Test of Central Hypothesis—Psychotropic Medications It is not surprising that more than two thirds of this population of people with SMI receive atypical antipsychotics and almost one third have typical antipsychotics as part of their medication regimen. After we stratified all of the dosings according to their equivalency, the analyses of the categories for atypical and typical antipsychotics showed a significant difference (see Figure 1). Despite our analysis not explaining causality this difference might be due to an increased amount and intensity of psychotic symptoms in a population with histories of childhood abuse as previously described (Bebbington et al., 2004). Higher dosing of antipsychotic medication might be an attempt to pharmacologically control these symptoms. There is a large overlap between dissociative and psychotic symptoms in people who have experienced SCE (Kluft, 1987; Moskowitz & Corstens, 2007). The presence of dissociative symptoms might be a reason for treatment refractory psychotic cases and the phenomenon of higher dosing just the unsuccessful attempt to treat those cases. Mood stabilizers also show a significant difference between the two subgroups. Garno et al. (2005) demonstrated an association between multiple forms of childhood abuse and complex forms of adult bipolar disorder. The increased use of mood stabilizers might be an attempt to treat these more complex and treatment refractory forms of affective symptoms. In addition, this category of medication is often used for the treatment of affective dysregulation. The increased dosing for the group of people with high SCE might be an effort to control this very common symptom in people with abuse histories (Read & Ross, 2003). The dosing of antidepressant medication is higher in the group of people with high SCE without reaching the level of significance. This group is



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very heterogeneous in regard to the individual substances, some of them having more sedating effects whereas others are more activating. A more in-depth analysis of the individual substances shows that more sedating substances (mirtazapine; see Table 1) appear to be used in higher dosing in people with high SCE, whereas more activating substances (fluoxetine; see Table 1) are used in people with low SCE. These differences suggest that an analysis of the group of antidepressants as a whole is not accurate enough and does not consider the broad range of indications for which these substances are used. The category of anxiolytics and hypnotics does not demonstrate a significant difference between the two subgroups; a trend toward people with high SCE taking higher doses is evident. Anda et al. (2007) reported a strong correlation between rates of prescription psychotropic drug use and ACE score in a population of members of a health appraisal clinic. In our population of people with SMI, the number of prescribed substances is generally high, with 2.9 different medications per person. This reflects, however, the prescription rates for people with SMI (Clark, Xie, & Brunette, 2004). An analysis of the individual substances yields no significant differences regarding the prescription rates. Although people with SMI and high SCE do not receive different or additional medication in this sample, they are given higher doses of antipsychotic medication and mood stabilizers.

Limitations This study had a retrospective design, and the information regarding SCE was based on participants’ recall. Nondisclosure of childhood adversities can influence the presented data and produce false-negative results; however, studies show that this is a rather uncommon event, depending on abuse severity and the age at which the abuse was experienced (Goodman et al., 2003). Freyd, DePrince, and Zurbriggen (2001) presented in their work that the ability to remember abuse is significantly linked to the victim’s dependence on the perpetrator. They postulated that both caregiver status and abuse duration may lead to denial, forgetting, and dissociation. Williams (1995) showed that women who had forgotten their childhood sexual abuse tended to be younger at the time of abuse and had less support from their mothers than women who always remembered their victimization. The analyzed sample describes a very specific population of people with SMI and is not representative of all people with SMI. The lack of a control group of people without SMI limits the generalizability of the study. The information about psychotropic medication was gathered from medical charts. The prescribed dose might not have been representative of the actual amount taken by the patient. The only way to avoid this possible bias is to measure blood drug levels. To minimize bias due to adherence issues we used the ROMI scale, showing no differences between the two subgroups. Because of the

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observational study design, no statement about causality or the presence of any kind of predictive relation can be made.


CONCLUSIONS As shown in this study, SCE are very prevalent in people with SMI, who often exhibit symptoms that cannot be ameliorated by treatment as usual. The interactions between traumatic events and symptoms are very complex and multifaceted. Based on these interactions it would be expected that clinicians would try to address these recalcitrant symptoms, among other interventions, by increasing the dosing of psychotropic medications. Our results show higher doses of antipsychotic and mood-stabilizing medication in the high SCE subgroup; there is a clear association between high exposure to SCE and higher dosing of atypical and typical antipsychotics as well as mood stabilizers. This prediction appears to be consistent with the notion that people who suffer from SMI and have had SCE are not optimally treated with psychopharmacologic treatment alone. More studies are needed to analyze the individual psychotropic medications and their benefit in the treatment of this population. Psychopharmacologic approaches should take trauma histories into consideration and include assessments of complex trauma symptoms, with a special focus on dissociative symptoms and symptoms of affective dysregulation. Further research should test these findings and confirm more severe and treatment refractory manifestations of psychiatric illnesses in this population. This study demonstrates that although people with SMI are affected by high rates of SCE, clinicians rarely assess or diagnose PTSD, complex PTSD, or DID in this population. This shows the necessity to screen for trauma and trauma-related symptoms in this patient population. Without proper diagnostic assessment, trauma-related symptoms can be missed, resulting in inadequate treatment, including overmedication. Best practices treatment includes using trauma-informed psychotherapeutic approaches and cognitive behavioral interventions in addition to being attentive to the potential for reducing medication loads, especially for people with SMI not labeled a priori as psychotic. In order to improve the assessment and diagnosis of trauma-related symptoms in people with SMI, clinicians and researchers ought to include standardized instruments to assess traumatic events (e.g., Traumatic Life Events Questionnaire; Kubany et al., 2000), trauma symptoms (e.g., Impact of Event Scale; Creamer, Bell, & Failla, 2003), complex PTSD (e.g., Symptoms of Trauma Scale; Opler, Grennan, & Opler, 2006), and dissociation (e.g., Dissociative Experiences Scale; Carlson et al., 1993). The use of these validated instruments will reduce the risk of having the data confounded and potentially invalidated by hidden trauma/dissociation, and clinicians will be able to more accurately diagnose and treat patients with SMI.


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ACKNOWLEDGMENT We declare no conflicts of interest.

FUNDING Downloaded by [Yeshiva University Libraries - Cardozo - Einstein - YU ] at 04:27 01 July 2014

This research was funded by the New York State Office of Mental Health.

REFERENCES Akuchekian, S., & Amanat, S. (2004). The comparison of topiramate and placebo in the treatment of posttraumatic stress disorder: A randomized, double-blind study. Journal of Research in Medical Sciences, 9(5), 240–244. Anda, R. F., Brown, D. W., Felitti, V. J., Bremner, J. D., Dube, S. R., & Giles, W. H. (2007). Adverse childhood experiences and prescribed psychotropic medications in adults. American Journal of Preventive Medicine, 32(5), 389–394. doi:10.1016/j.amepre.2007.01.005 Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry & Clinical Neuroscience, 256(3), 174–186. doi:10.1007/s00406-005-0624-4 Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E., & Caspi, A. (2011). Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. American Journal of Psychiatry, 168(1), 65–72. doi:10.1176/appi.ajp.2010.10040567 Ashton, H. (1987). Benzodiazepine withdrawal: Outcome in 50 patients. British Journal of Addiction, 82, 665–671. Ashton, H. (1994). Guidelines for the rational use of benzodiazepines: When and what to use. Drugs, 48(1), 25–40. Bartzokis, G., Lu, P. H., Turner, J., Mintz, J., & Saunders, C. S. (2005). Adjunctive risperidone in the treatment of chronic combat-related posttraumatic stress disorder. Biological Psychiatry, 57, 474–479. doi:10.1016/j.biopsych.2004.11.039 Bebbington, P. E., Bhugra, D., Brugha, T., Singleton, N., Farrell, M., Jenkins, R., . . . Meltzer, H. (2004). Psychosis, victimisation and childhood disadvantage: evidence from the second British National Survey of Psychiatric Morbidity. British Journal of Psychiatry, 185, 220–226. doi:10.1192/bjp.185.3.220 Carlson, E. B., Putnam, F. W., Ross, C. A., Torem, M., Coons, P., Dill, D. L., . . . Braun, B. G. (1993). Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: A multicenter study. American Journal of Psychiatry, 150, 1030–1036. Castille, D. M., Muenzenmaier, K. H., & Link, B. G. (2011). Coercion—Point, perception, process. In T. W. Kallert, J. E. Mezzich, & J. Monahan (Eds.), Coercive treatment in psychiatry (pp. 245–267). New York, NY: Wiley.


508


Centorrino, F., Sani, G., Fogarty, K. V., Salvatore, P., Talamo, A., Cincotta, S. L., & Baldessarini, R. J. (2006). Combinations of mood-stabilizers with antipsychotics as treatment strategies in hospitalized psychiatric patients. Clinical Neuropsychiatry, 3(5), 322–326. Chu, J. A. (2005). Guidelines for treating dissociative identity disorder in adults (2005). Journal of Trauma & Dissociation, 6(4), 69–149. Clark, R. E., Xie, H., & Brunette, M. F. (2004). Benzodiazepine prescription practices and substance abuse in persons with severe mental illness. Journal of Clinical Psychiatry, 65(2), 151–155. Creamer, M., Bell, R., & Failla, S. (2003). Psychometric properties of the Impact of Event Scale–Revised. Behavior Research and Therapy, 41, 1489–1496. Duffy, J. D., & Malloy, P. F. (1994). Efficacy of buspirone in the treatment of posttraumatic stress disorder: An open trial. Annals of Clinical Psychiatry, 6(1), 33–37. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. Fesler, F. A. (1991). Valproate in combat-related posttraumatic stress disorder. Journal of Clinical Psychiatry, 52(9), 361–364. First, M. B., & Gibbon, M. (2004). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). In M. J. Hilsenroth & D. L. Segal (Eds.), Comprehensive handbook of psychological assessment: Vol. 2. Personality assessment (pp. 134–143). Hoboken, NJ: Wiley. Foote, B., Smolin, Y., Kaplan, M., Legatt, M. E., & Lipschitz, D. (2006). Prevalence of dissociative disorders in psychiatric outpatients. American Journal of Psychiatry, 163, 623–629. doi:10.1176/appi.ajp.163.4.623 Ford, J. D., & Courtois, C. A. (2009). Conclusion. The clinical utility of a complex traumatic stress disorders framework. In J. D. Ford & C. A. Courtois (Eds.), Defining and understanding complex trauma and complex traumatic stress disorder (pp. 441–453). New York, NY: Guilford Press. Freyd, J. J., DePrince, A. P., & Zurbriggen, E. L. (2001). Self-reported memory for abuse depends upon victim-perpetrator relationship. Journal of Trauma & Dissociation, 2(3), 5–16. doi:10.1300/J229v02n03_02 Friedman, M. J., & Davidson, J. R. T. (2010). Pharmacotherapy for PTSD. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 376–405). New York, NY: Guilford Press. Gardner, D. M., Murphy, A. L., O’Donnell, H., Centorrino, F., & Baldessarini, R. J. (2010). International consensus study of antipsychotic dosing. American Journal of Psychiatry, 167, 686–693. doi:10.1176/appi.ajp.2009.09060802 Garno, J. L., Goldberg, J. F., Ramirez, P. M., & Ritzler, B. A. (2005). Impact of childhood abuse on the clinical course of bipolar disorder. British Journal of Psychiatry, 186, 121–125. doi:10.1192/bjp.186.2.121 Goodman, G. S., Ghetti, S., Quas, J. A., Edelstein, R. S., Alexander, K. W., Redlich, A. D., . . . Jones, D. P. (2003). A prospective study of memory for child



509

sexual abuse: new findings relevant to the repressed-memory controversy. Psychological Science, 14(2), 113–118. Hasin, D. S., Trautman, K. D., Miele, G. M., Samet, S., Smith, M., & Endicott, J. (1996). Psychiatric Research Interview for Substance and Mental Disorders (PRISM): Reliability for substance abusers. American Journal of Psychiatry, 153, 1195–1201. Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627. doi:10.1001/archpsyc.62.6.617 Kluft, R. P. (1987). First-rank symptoms as a diagnostic clue to multiple personality disorder. American Journal of Psychiatry, 144(3), 293–298. Kubany, E. S., Haynes, S. N., Leisen, M. B., Owens, J. A., Kaplan, A. S., Watson, S. B., & Burns, K. (2000). Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment, 12(2), 210–224. Link, B., Castille, D. M., & Stuber, J. (2008). Stigma and coercion in the context of outpatient treatment for people with mental illnesses. Social Science & Medicine, 67, 409–419. doi:10.1016/j.socscimed.2008.03.015 Majer, M., Nater, U. M., Lin, J. M., Capuron, L., & Reeves, W. C. (2010). Association of childhood trauma with cognitive function in healthy adults: A pilot study. BMC Neurology, 10, 61. Retrieved from http://www.biomedcentral.com/14712377/10/61. doi:10.1186/1471-2377-10-61 Meyer, I. H., Muenzenmaier, K., Cancienne, J., & Struening, E. (1996). Reliability and validity of a measure of sexual and physical abuse histories among women with serious mental illness. Child Abuse & Neglect, 20(3), 213–219. Moskowitz, A., & Corstens, D. (2007). Auditory hallucinations: Psychotic symptom or dissociative experience? Journal of Psychological Trauma, 6(2–3), 35–63. doi:10.1300/J513v06n02_04 Muenzenmaier, K., Schneeberger, A. R., Castille, D. M., Battaglia, J., Seixas, A. A., & Link, B. G. (2014). Stressful childhood experiences and clinical outcomes in people with serious mental illness: A gender comparison in a clinical psychiatric sample. Journal of Family Violence, 29(4), 419–429. Muenzenmaier, K., Spei, E., & Gross, D. R. (2010). Complex posttraumatic stress disorder in men with serious mental illness: A reconceptualization. American Journal of Psychotherapy, 64(3), 257–268. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD, and the course of severe mental illness: An interactive model. Schizophrenia Research, 53(1–2), 123–143. Nose, M., Cipriani, A., Biancosino, B., Grassi, L., & Barbui, C. (2006). Efficacy of pharmacotherapy against core traits of borderline personality disorder: Meta-analysis of randomized controlled trials. International Clinical Psychopharmacology, 21(6), 345–353. doi:10.1097/01.yic.0000224784.90911.66 Opler, L., Grennan, M., & Ford, J. (2009). Pharmacotherapy. In M. Cloitre, L. R. Cohen, & K. C. Koenen (Eds.), Treating survivors of childhood abuse: Psychotherapy for the interrupted life (pp. 329–349). New York, NY: Guilford Press.


510


Opler, L. A., Grennan, M. S., & Opler, M. G. (2006). Pharmacotherapy of post-traumatic stress disorder. Drugs of Today, 42, 803–809. doi:10.1358/dot.2006.42.12.1025704 Phelan, J. C., Sinkewicz, M., Castille, D. M., Huz, S., Muenzenmaier, K., & Link, B. G. (2010). Effectiveness and outcomes of assisted outpatient treatment in New York state. Psychiatric Services, 61(2), 137–143. doi:10.1176/appi.ps.61.2.137 Putnam, K. T., Harris, W. W., & Putnam, F. W. (2013). Synergistic childhood adversities and complex adult psychopathology. Journal of Traumatic Stress, 26, 435–442. doi:10.1002/jts.21833 Read, J., Agar, K., Argyle, N., & Aderhold, V. (2003). Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychology and Psychotherapy: Theory, Research and Practice, 76(1), 1–22. doi:10.1348/14760830260569210 Read, J., Fink, P., Rudegeair, T., Felitti, V., & Whitfield, C. (2008). Child maltreatment and psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia & Related Psychoses, 2, 235–254. Read, J., Perry, B. D., Moskowitz, A., & Connolly, J. (2001). The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry, 64(4), 319–345. Read, J., & Ross, C. A. (2003). Psychological trauma and psychosis: Another reason why people diagnosed schizophrenic must be offered psychological therapies. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31(1), 247–268. Reich, D. B., Winternitz, S., Hennen, J., Watts, T., & Stanculescu, C. (2004). A preliminary study of risperidone in the treatment of posttraumatic stress disorder related to childhood abuse in women. Journal of Clinical Psychiatry, 65, 1601–1606. Rosenberg, S. D., Lu, W., Mueser, K. T., Jankowski, M. K., & Cournos, F. (2007). Correlates of adverse childhood events among adults with schizophrenia spectrum disorders. Psychiatric Services, 58(2), 245–253. doi:10.1176/appi.ps.58.2.245 Ross, C. A. (2006). The trauma model: A solution to the problem of comorbidity in psychiatry. Richardson, TX: Manitou Communications. Saunders, J. B., & Yang, J. (2002). Clinical protocols for detoxification in hospitals and detoxification facilities. Brisbane, Australia: Alcohol and Drug Services, Royal Brisbane Hospital and The Prince Charles Hospital Health Service Districts. Sautter, F. J., Brailey, K., Uddo, M. M., Hamilton, M. F., Beard, M. G., & Borges, A. H. (1999). PTSD and comorbid psychotic disorder: Comparison with veterans diagnosed with PTSD or psychotic disorder. Journal of Traumatic Stress, 12(1), 73–88. doi:10.1023/A:1024794232175 Schafer, I., & Fisher, H. L. (2011). Childhood trauma and psychosis—What is the evidence? Dialogues in Clinical Neuroscience, 13(3), 360–365. Schafer, I., Ross, C., & Read, J. (2008). Childhood trauma in psychotic and dissociative disorders. In A. Moskowitz, I. Schafer, & M. J. Dorahy (Eds.), Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology (pp. 135–150). New York, NY: Wiley.



511

Schneeberger, A. R., Muenzenmaier, K., Battaglia, J., Castille, D. M., & Link, B. G. (2012). Childhood abuse, head injuries, and use of medical emergency services in people with severe mental illness. Journal of Aggression, Maltreatment & Trauma, 21, 570–582. doi:10.1080/10926771.2012.678468 Spauwen, J., Krabbendam, L., Lieb, R., Wittchen, H. U., & van Os, J. (2006). Impact of psychological trauma on the development of psychotic symptoms: Relationship with psychosis proneness. British Journal of Psychiatry, 188, 527–533. doi:10.1192/bjp.bp.105.011346 Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., . . . Bentall, R. P. (2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661–671. doi:10.1093/schbul/sbs050 Weiden, P., Rapkin, B., Mott, T., Zygmunt, A., Goldman, D., Horvitz-Lennon, M., & Frances, A. (1994). Rating of Medication Influences (ROMI) scale in schizophrenia. Schizophrenia Bulletin, 20(2), 297–310. Weilburg, J. B., O’Leary, K. M., Meigs, J. B., Hennen, J., & Stafford, R. S. (2003). Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatric Services, 54, 1233–1239. Williams, L. M. (1995). Recovered memories of abuse in women with documented child sexual victimization histories. Journal of Traumatic Stress, 8, 649–673.