Q. Hamid. Pacific Lutheran University.

I’d also like to mention Bev Hisee purchase aldactone 25mg overnight delivery, Research Nurse generic 25 mg aldactone with amex, who assisted me greatly in my interactions with consumers and whose knowledge and genuineness impressed generic 25mg aldactone visa. To the incredible group of interviewees involved in this research and to those consumers who I met along the way – this thesis would not have been possible without your insightful contributions. Thank you for your openness, cooperation and for your fascinating stories that have brought this thesis to life. To my family, in particular, my parents, Joe and Carol, thanks for putting up with me and for putting a roof over my head for all these years. You have always been there for me to rely on and I cannot thank you enough for your ongoing belief in me. To my beautiful sister, Rebecca, my brother- in-law, Josh, and the adorable Moll - thank you for opening up your home to me and for giving me perspective during the tough times. The extent to which individuals with diagnoses of schizophrenia adhere to their antipsychotic medications is considered an important influence on their outcomes. Whilst medication adherence amongst people with schizophrenia has been studied extensively, the majority of research has been quantitative and thus, the voices of consumers have largely been neglected. One reason that has been proposed for this absence is the assumption that people with schizophrenia would not be able to provide meaningful contributions to knowledge. This thesis aims to redress the dearth of consumers’ voices in adherence research by examining their perspectives through qualitative interviews. Analysis of interview data supports the significant value of the inclusion of consumers’ voices in research to enhance understanding of medication adherence. According to Freedman (2005), schizophrenia is a chronic disability of mental and social function, with superimposed, recurrent episodes of exacerbated psychotic symptoms, such as delusions and/or hallucinations. Despite being considered one of the most severe, disabling and economically draining mental illnesses (Picchioni & Murray, 2007), Schneider (2010) points out that people diagnosed with schizophrenia can and do participate in valued social roles and lead satisfying, productive lives, consistent with research on 1 recovery in schizophrenia (Liberman & Kopelowicz, 2005; Resnick, Rosenheck & Lehman, 2004). This chapter will summarise the symptoms of schizophrenia according to the medical model. This is followed by a discussion of the social constructionist position as an alternative perspective for understanding mental illness and schizophrenia in particular. An understanding of what schizophrenia is and the epidemiology of schizophrenia has been included in an attempt to contextualise the sample of interviewees, by describing the accepted view of what people with schizophrenia in the general population experience in terms of illness symptoms as well as the associated outcomes. Critically, some of the unsettling statistics regarding the significant impact that schizophrenia has on the lives of consumers and the community reinforce the benefits of research aimed at improving the outcomes for people with schizophrenia. A clinical diagnosis of schizophrenia requires the presence of delusions and/or hallucinations, formal thought disorder and unusual behaviour lasting for at least one month, with significant social and occupational deterioration experienced prior or subsequent to psychotic symptoms (Picchioni & Murray, 2007; Sharif, Bradford, Stroup & Lieberman, 2007). People with a diagnosis of schizophrenia typically experience symptoms which are consistently described by the dominant medical model of clusters of positive, negative and cognitive symptoms. However, some individuals may predominantly experience symptoms from positive or negative clusters, respectively (Cutting, 2003). Positive symptoms are so called because they are considered an addition to a person’s repertoire (Birchwood & Jackson, 2001). Positive symptoms include things such as delusions, unusual thoughts and suspiciousness, paranoia, hallucinations and distorted perceptions typically considered to be manifestations of psychosis (McEvoy, Scheifler & Frances, 1999). Negative symptoms are those that are evident by the blunting of motivation and emotion; for example, social withdrawal, lack of energy, loss of sense of pleasure, inability to make decisions, limited speech and poor self care (Smith, Weston & Lieberman, 2009). Negative symptoms persist even in the absence of positive symptoms during periods of remission; however, they may be secondary to other factors, such as depression (McGorry, 1992). Cognitive symptoms common to people with schizophrenia include problems with attention, learning new information, memory, verbal fluency, problem solving, recognising social cues, confused thinking, disorganised speech and disorganised behaviour (Freedman, 2005; McEvoy et al. It is estimated that approximately 75% of people with schizophrenia have clinically meaningful deficits in at least two cognitive domains and 90% have deficits in one (Sharif et al. An alternative medical model of schizophrenia that is also often deployed by researchers is comprised of clusters of positive, negative and disorganised symptoms (Beck, Rector, Stolar & Grant, 2009; Cutting, 2003; Sharif et al. Such models typically group cognitive impairments (such 3 as impairments in attention, learning, memory and perception) in the negative symptom cluster. Disorganisation symptoms include disordered thought processes, bizarre behaviour and disturbances of emotions or inappropriate affect (Cutting, 2003; Sharif et al. Specifically, the paranoid type describes individuals who experience delusions (persecutory or grandiose) or hallucinations but thought disorder, disorganised behaviour and negative symptoms are absent. Individuals are diagnosed as the disorganised type when they present with both thought disorder and flattened affect. The catatonic type defines those who exhibit agitated, purposeless movement or are immobile. The undifferentiated type is diagnosed in cases when psychotic symptoms are present but do not meet criteria for the paranoid, disorganised or catatonic types. The residual type is diagnosed when individuals experience mild positive symptoms only. The above descriptions of schizophrenia are based on the current, dominant construction of schizophrenia as a mental illness or pathology, in line with psychiatry’s medical model. Schneider (2010) highlights the fact that schizophrenia has not always regarded as an illness in line with the current dominant medical model of health, as the ever-changing historical accounts of schizophrenia or “madness” indicate. There is also a significant social constructionist literature which suggests that “schizophrenia” is but a disease metaphor which has gained acceptance as a bio-psychiatric entity despite a lack of evidence (Wise, 2004). By a lack of evidence, researchers allude to an absence of medical tests to confirm a diagnosis, no clear causes identified and there being no consistent set of symptoms present in all cases (Schneider, 2010). Advocates of this 4 position dispute the use of diagnostic labels to describe people’s experiences and regard terminology such as “schizophrenia” and “mental illness” as mechanistic social constructions of deviant behaviour which are morally based and serve stigmatising functions (Schneider, 2010; Wise, 2004). The medical management of what is, ultimately, considered to be unwanted conduct according to some moral standard is, thus, also frequently contested by proponents of a social constructionist position (Wise, 2004). Whilst I acknowledge the social constructionist position and am sympathetic towards it, I use the terms ‘schizophrenia’ and ‘mental illness’ throughout this thesis. The term ‘schizophrenia’ has been used to describe people who have been given a diagnosis of the illness from a mental health professional based on meeting the present criteria of the current medical model of schizophrenia. As Schneider (2010, p18) states: “While I acknowledge the difficulties of using the word schizophrenia, our research is an attempt to change the meanings of this word by demonstrating the ability of people diagnosed with schizophrenia to make a significant contribution to knowledge about schizophrenia”. I refer to people with schizophrenia as “consumers” throughout the present study, to reflect the interaction between individuals and the health system. Whilst this reflects more politically correct terminology, the results of the present study indicate that the term “consumer” may not adequately describe the interaction between people with 5 schizophrenia and the health system, which in actuality is often entrenched with power imbalances in the favour of service providers(this interaction will be elaborated further in Chapter 7). It is acknowledged that some commentators have criticised use of the term “consumers” as a descriptor, as it implies that people with schizophrenia are aware that they have an illness and are thus, able to make treatment choices, which may not be the case amongst people who lack insight (i. Of note, there is a lack of consensus regarding the contributions of each of these risk factors and how they interact (Smith et al. The lifetime prevalence rate of schizophrenia has been estimated at approximately 0. Although these figures may appear modest, schizophrenia rates among the top ten causes of long- term disability in the world (Compton, 2007). The onset of schizophrenia symptoms typically occurs in adolescence and early adulthood (average age 25 years), although it can affect people at any age (Smith et al. The epidemiology for schizophrenia has undergone a major shift in the past decade (Beck et al. The prevailing view of the 1980s and 1990s was that schizophrenia occurs at similar rates in all populations around the world, irrespective of individual or group 6 characteristics such as gender and culture. This accepted notion rendered epidemiological studies seeking to identify risk factors for schizophrenia negligible as such studies would require heterogeneity in prevalence between groups and populations (Menezes, 2009). A recent renewed interest in the epidemiology of schizophrenia, especially in relation to incidence and outcomes, in conjunction with results from systematic reviews in the field have led to the replacement of received notions about schizophrenia with a more nuanced perspective. This systematic review yielded wide variation in the incidence rates of schizophrenia across populations, regions and groups. Namely, it was found that incidence rates vary considerably cross- culturally, with a fivefold variation observed between central estimates. Males also tend to develop schizophrenia earlier in life than females (Beck et al. Furthermore, it has been reported that males experience more severe symptoms, more negative symptoms, have less chance of recovery and have generally worse outcomes than females (Picchioni & Murray, 2007). The incidence of schizophrenia appears to be declining as it has recently been estimated at 0. Those born or residing in urban areas are reported to be at greater risk of developing schizophrenia than those born or residing in rural areas (Menezes, 2009). Migrants are additionally thought to be at greater risk of developing schizophrenia (Beck et al. Whilst the prevalence of schizophrenia in indigenous communities in Australia is unknown, elevated rates of hospitalisation and pervasive 7 disadvantage affecting communities suggest that the prevalence may be higher than in the wider community (Australian Institute of Health and Welfare, 2011).

Web- Communicating about medications during based collaborative care for type 2 diabetes: primary care outpatient visits: the role of a pilot randomized trial generic aldactone 25 mg mastercard. Effect of an electronic medication insight: a qualitative cross-site study of reconciliation application and process physician order entry buy generic aldactone 25mg on-line. Stud Health Technol redesign on potential adverse drug events: a Inform 2004;107(Pt:2):2-7 buy 25mg aldactone fast delivery. J Am Med Inform Assoc Effects of a subcutaneous insulin protocol, 2003;10(2):188-200. Perceptions of house officers who use Physicians’ prescribing attitudes to physician order entry. Implementing computerized physician order entry: the importance of special people. Pharmacoepidemiology & Drug field: Lessons learned in a multi-center Safety 2009;18(8):751-5. Physicians’ perceptions of Computerized Provider Order Entry--what possibilities and obstacles prior to are health professionals concerned about? Beuscart-Zephir M-C, Pelayo S, Bernonville decision support system has the potential to S. Health Aff (Millwood) limited acceptance of an electronic 2007;26(3):w393-w404 prescription system by general practitioners: 343. Home computerized physician order entry systems telemanagement for patients with ulcerative in facilitating medication errors. Workarounds to barcode medication Variation in electronic prescribing administration systems: their occurrences, implementation among twelve ambulatory causes, and threats to patient safety. The story behind the story: during transition to a computer physician physician skepticism about relying on order entry: what they are and what they clinical information technologies to reduce mean. Journal of we setting about improving the safety of Pharmacy & Pharmaceutical Sciences computerised prescribing in the right way? J Am Improving patient safety by identifying side Med Inform Assoc 2007;14(1):65-75. Exploring barriers and facilitators to the use Some unintended consequences of clinical of computerized clinical reminders. The extent and importance of unintended consequences related to computerized provider order entry. Categorizing the unintended sociotechnical consequences of computerized provider order entry. Overdependence on technology: an unintended adverse consequence of computerized provider order entry. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study. Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting. Associate Professor Department of Pediatrics Vanderbilt University Medical Center Kevin Marvin, R. Assistant Professor of Medicine Assistant Professor of Obstetrics, Gynecology and Reproductive Science Assistant Professor of Epidemiology University of Pittsburgh Dennis Tribble, Pharm. Exclude - Not a Primary Study Bar-coded unit doses: Coming to a hospital near you. Exclude - Not a Primary Study Automated decentralized pharmacy dispensing systems. Improving the drug distribution process--do you need an automated decentralized pharmacy dispensing system? Exclude - Not a Primary Study Top-priority actions for preventing adverse drug events in hospitals: Recommendations of an expert panel. Exclude - Not a Primary Study Physician order entry system cuts error rate, improves path compliance, tracks data. Exclude - Not a Primary Study Proceedings of the 1997 9th Annual Quest for Quality and Productivity in Health Services. Exclude - Not a Primary Study Electronic point-of-care prescribing: Selling the benefits, identifying initial steps for success. Exclude - Not a Primary Study Can an automatic alert system eliminate medication errors? Exclude - Not a Primary Study Electronic prescribing reduces Rx costs, boosts generic utilization for physician group. Exclude - Not a Primary Study Patient safety/medication safety: the impact of computerized physician order entry on medication error prevention in hospitalized patients (project). The Netherlands Organisation for Health Research and Development (ZonMw) 2000; http://www. Exclude - Not a Primary Study Bar code labeling standards proposed for drug product packaging. Exclude - Not a Primary Study Making health care safer: A critical analysis of patient safety practices. Exclude - Not a Primary Study Can e-prescribing reduce drug costs under capitation? Exclude - Not a Primary Study What’s hot in the chain drug market - A report on the technology agenda based on a survey of nearly 40 large and small chains. Exclude - Not a Primary Study Advanced technologies to lower healthcare costs and improve quality. Exclude - Not a Primary Study Scanning medication barcodes improves accuracy at Lehigh Valley Hospital. Exclude - Not a Primary Study Use these tools to comply with patient safety goals. Exclude - Not a Primary Study Computer feedback promotes generic drug prescribing. Exclude - No Outcomes of Interest e-prescriptions: Surescripts making a difference? Exclude - Not a Primary Study E-scripts to provide new loyalty opportunities for pharmacy. Exclude - Not a Primary Study Where we are headed with technology - What industry executives have to say. Exclude - Not a Primary Study “As directed” is never acceptable for prescription directions and frequency. Exclude - Not a Primary Study At a tipping point: Transforming medicine with health information technology a guide for consumers. Exclude - Not a Primary Study Bar coding helps hospitals reduce medication errors. Exclude - Not a Primary Study Medication safety issue brief: Bar code implementation strategies. Exclude - Not a Primary Study Strategies to reduce medication errors with reference to older adults. Exclude - Not a Primary Study Study shows limited use of electronic medical records. Exclude - Not a Primary Study A primer on the new physician self-referral exceptions and anti-kickback safe harbors for electronic prescribing and electronic health records technology. Exclude - Not a Primary Study Health information technology promotion act of 2006. Exclude - Not a Primary Study Ontario’s medication management system - Transformation wanted! Exclude - Not a Primary Study Regulatory changes affecting health information exchanges. Exclude - Not a Primary Study Saving lives, reducing costs: Computerized physician order entry lessons learned in community hospitals. Exclude - Not a Primary Study Barriers to equitable access to quality health information with emphasis on developing countries. Exclude - Not a Primary Study Designing inherent safety into electronic medication order entry systems. Exclude - Not a Primary Study Determining health informatics workforce needs in developing countries.

The regions that are homologous are sometimes on a chromosome referred to as pseudoautosomal regions buy 25mg aldactone with mastercard. During meiosis-l of male spermatogenesis purchase aldactone 25mg with visa, the X and Y chromosomes pairin the pseudoautosomal regions discount aldactone 25mg without prescription, allowing the chromo- Allele-different forms of a somes to segregate int~ different cells. When a specific site on a chromosome has multiple alleles in the locus are different population, it is said to be polymorphic (many forms). Throughout human to produce disease history there have been many mutations in the ~-globin gene, and each mutation has created a new allele in the population. Some alleles cause Recessive-requires two no clinical disease, but others, like the sickle cell allele, are associated with significant disease. Note Phenotype The phenotype is generally understood as the expression of the genotype in terms of observable Major types of single-gene characteristics. Missense mutations result in the substitution of a single amino acid in the polypeptide chain (e. Nonsense mutations produce a stop codon,, • Frameshift resulting in premature termination of translation and a truncated protein. When the number of inserted or deleted bases is a multiple of three, the mutation is said to be in-frame. Mutations that cause a missing protein product or cause decreased activity of the protein are termed loss-of function. Those that produce a protein product with a new function or increased activity are termed 1 gain-of function. Recurrence risk The recurrence risk is the probability that the offspring of a couple will express a genetic disease. It is important to remember that each reproductive eventis statistically independent of all previous events. Therefore, the recur- rence risk remains the same regardless of the number of previously affected or unaffected offspring. The first affected individual to be identified in the family is termed the proband. Skipped generations are not typically seen because two Unaffected parents cannot transmit a disease-causing allele to their offspring (an exception occurs when there is reduced penetrance, discussed below). Autosomal dominant alleles are relatively rare in populations, so the typical mating pattern is a heterozygous affected individual (Aa genotype) mating with a homozygous normal individual (aa genotype), as shown in Figure I1-1-3. Note that, by convention, the dominant allele is shown in uppercase (A) and the recessive allele is shown inlowercase (a). The recurrence risk is thus 50%, and half the children, on average, will be affected with the disease. Autosomal Dominant Inheritance • Neurofibromatosis type 1 • Marfan syndrome Acute intermittent porphyria A a a aa a aa Attected offspring (Aa) are shaded. Recurrence Risk for the Mating of Affected Individual (Aa) with a Homozygous Unaffected Individual (aa) Autosomal Recessive Inheritance Important features that distinguish autosomal recessive inheritance: • Because autosomal recessive alleles are clinically expressed only in the homozygous state, the offspring must inherit one copy of the disease-causing allele from each parent. In contrast to autosomal dominant diseases, autosomal recessive diseases are typically. This mechanism, termed X inactivation, occurs in the i" chromosomes but one are blastocyst (-100 cells) during the development of female embryos. X inactivation has several important characteristics: o It is random-in some cells of the female embryo, the X chromosome inherited from Note the father is inactivated, and in others the X chromosome inherited from the mother is inactivated. Thus, as a condition in which cells • females are said to be mosaics with respect to the active X chromosome. For example, females with three X chromosomes in each cell (see Chapter 3) have two X chromosomes inacti- vated in each cell (thus, two Barr bodies can be visualized in an interphase cell). Inactivation of the X Chromosome During Embryogenesis Is a Random Process,I I I Properties of X-linked recessive inheritance! Skipped generations are commonly seen because an affected male can transmit the disease-causing mutation to a heterozygous daughter, who is unaffected but who can transmit the disease-causing allele to her sons. Male-to-male transmission is not seen in X-linked inheritance; this helps distinguish it from autosomal inheritance. Affected male-homozygous normal female: All of the daughters will be heterozygous carriers; all of the sons will be homozygous normal. Normal male-carrier female: On average, half of the sons will be affected and half of the daughters will be carriers. Affected male-homozygous normal female (X chromosome with mutation is in lower case) B. However, because X inactivation is a random process, a het- erozygous female will occasionally express an X-linked recessive mutation because; by random chance, most of the X chromosomes carrying the normal allele have been inactivated. Single-Gene Disorders X-Linked Dominant Inheritance Clinical Correlate There are relatively few diseases whose inheritance is classified as X-linked dominant. In this condition, females are differently affected than Males: 100% penetrance males, and whereas penetrance in males is 100%, that in females is approximately 60% (see margin note). Because females have two X chromosomes (and • Macro-orchidism (usually il thus two chances to inherit an X-linked disease-causing mutation) and males have only postpubertal) one, X-linked dominant diseases are seen about twice as often in females as in males. None of his sons will I be affected, but all of his daughters have the disease (assuming complete penetrance). X-Linked Dominant Inheritance Recurrence Risks Figure 11-1-10 shows the recurrence risks for X-linked dominant inheritance. Affected male-homozygous normal female (the mutation-carrying chromosome is upper case) B. X-linked Autosomal Autosomal May be X- recessive recessive dominant dominant Are all daughters of an affected male also affected? Note: If transmission occurs only through affected mothers and never through affected sons, the pedigree is likelyto reflect mitochondrial inheritance. Sometimes a specific muta- tion is seen in only some of the mitochondria, a condition known as heteroplasmy. She takes no prescription drugs although she does use tu:1; ill aspirin for the hip pain. A liver biopsy revealed stainable iron in all hepatocytes and initial indications of hepatic I,,I I cirrhosis. Subsequently Mary was tested and also proved to be homozygous for the I,I Q82Y mutation. The autosomal recessive disease xeroderma pigmentosum will be expressed more severely in individuals who are exposed more frequently to ultraviolet radiation. Different mutations in the disease-causing locus may cause more- or less-severe expression. Allelic heterogeneity usually results in phenotypic variation between families, not within a single family. Generally the same mutation is responsible for all cases of the disease within a family. In the example of hemochromatosis above, both Mary and her brother have inherited the same mutation; thus, allelic heterogeneity is not responsible for the variable expression in this case. It is relatively uncommon to see a genetic disease in which there is no allelic heterogeneity. Disease expression may be affected by the action of other loci, termed modifier loci. Incomplete Penetrance A disease-causing mutation is said to have incomplete penetrance when some individuals who have the disease genotype (e. In the pedigree shown in Figure 11-1-13, Individual 11-4must have the disease-causing allele (he passed it from his father to his son) but shows no symptoms. Notice that hereditary hemochromatosis is an example of incomplete penetrance and also an example of variable expression. Expression of the disease phenotype in individuals homozy- gous for the disease-causing mutation can run the gamut from severe symptoms to none at all. Among the 15% of individuals with at least some phenotypic expression, that expression can be more or less severe (variable expression). However, 85% of individuals homozygous for the disease-causing mutation never have any symptoms (nonpenetrance), The same factors that contribute to variable expression in hemochromatosis can also contribute to incomplete.

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