Symptomatology and medication monitoring for public mental health consumers: A cultural perspective

Journal of the American Psychiatric Nurses Association

Symptomatology and Medication Monitoring for Public Mental Health Consumers: A Cultural Perspective Wilma J. Lutz, RN, CS, FNP, PhD, and Barbara Jones Warren, RN, CNS, CS, PhD

BACKGROUND: With the increased focus and impetus on pharmacological interventions, psychiatric mental health nurses have become concerned about consumers’ ability to understand and monitor their symptoms and medications. OBJECTIVE: The purpose of this study was to examine the relationship among cultural factors, stressors, moderators, medication monitoring, and psychiatric symptoms in consumers with severe mental disorders. STUDY DESIGN: This study is a cross-sectional analysis of data from a longitudinal research project conducted in Ohio. The sample was comprised of 199 consumers receiving community-based services within the public mental health system. RESULTS: Age, gender, and race were associated with indicators of medication monitoring. The model explained 51% of the variance in depression, 35% in anxiety, and 43% in psychoticism. CONCLUSION: Consumers’ culture is an important facet in the manifestation of psychiatric symptoms and the ability to monitor medications. (J Am Psychiatr Nurses Assoc [2001]. 7, 115-124.)

M

edication use for consumers of mental health care is an ongoing concern across the United States (Lin, Poland, & Anderson, 1995). Medication monitoring and management are important issues to psychiatric mental health (PMH) nurses because nurs-

Wilma J. Lutz, RN, CS, FNP, PhD, is a research administrator at the Ohio Department of Mental Health, Columbus. Barbara Jones Warren, RN, CNS, CS, PhD, is an associate professor of nursing at the Ohio State University College of Nursing, Columbus. Supported by a grant from the Ohio Department of Mental Health, awarded to Dee Roth, Chief, Office of Program Evaluation and Research. Reprint requests: Wilma J. Lutz, RN, CS, FNP, PhD, Ohio Department of Mental Health, Office of Program Evaluation and Research, 30 East Broad St., Suite 1170, Columbus, OH 43215-3430. Copyright © 2001 by the American Psychiatric Nurses Association. 1078-3903/2001/$35.00 + 0 66/1/117879 doi:10.1067/mpn.2001.117879

August 2001

es actively assist consumers in understanding the role of medications in their lives and the effect they have on their disorders (Glod & Levy, 1998; Haber, Krainovich-Miller, McMahon, & Price-Hoskins, 1998; Keltner, 1999; Stuart & Laraia, 1998). Four trends have contributed to PMH nurses’ interest in issues regarding consumers’ symptoms and medication monitoring. First, the use of pharmacological interventions has become an integral part of psychiatric treatment since the emergence of new classes of psychotropic medications in the 1950s (American Psychiatric Nurses Association, 1997; Haber et al., 1998). Second, the National Institute of Mental Health ushered in the Decade of the Brain during the 1990s, which created an impetus regarding research on the brain and the effect of pharmaceutical interventions on clients. Third, pharmaceutical companies have developed an increased number and variety of drugs for use in the treatment of psychiatric disorders. Finally, since the Decade of the Brain, nurse researchers have expanded their traditional focus on psychosocial variables and have begun to systematically and consistently integrate biological variables into their investigations. Subsequent research has provided new knowledge

APNA Web site: www.apna.org 115

Lutz and Warren

Journal of the American Psychiatric Nurses Association

Figure 1. Recovery and Monitoring Model.

and insights into issues associated with consumers’ medication usage. The purpose of this study was to build on this evolving research using a holistic framework that guides the practice of PMH nursing. BACKGROUND Study Framework The Recovery and Monitoring Model (Figure 1) was developed by the authors and used to guide this investigation. Concepts from O’Connor’s (1991, 1994) vulnerability-stress framework provided a foundation for the study model. O’Connor’s model focuses on psychotic symptoms and was designed to explain the contributions of stressors (e.g., neurological dysfunction, psychobiological factors, environmental factors, and interpersonal relationships) and moderators (e.g., stress regulation, symptom regulation, skill competencies, perceived social support, and antipsychotic medication effectiveness) in the production of these symptoms. The Recovery and Monitoring Model includes both stressors and moderators but also integrates additional factors important to understanding the manifes-

116 APNA Web site: www.apna.org

tation of psychiatric symptoms and medication usage by consumers within a public mental health system. The model includes cultural factors (e.g., race, gender, and age), involves symptoms associated with other psychiatric diagnoses, such as mood and anxiety disorders, and incorporates the concept of recovery.

Culture is defined as the internal and external manifestation of an individual, group, or community’s beliefs, values, and norms that are used as premises for everyday functioning. In the model, culture is defined as the internal and external manifestation of an individual, group, or community’s beliefs, values, and norms that are used as premises for everyday functioning. Culture may encompass a multitude of culturally and ethnically diverse domains, such as age, gender, socioeconomic status, religion, deafness, race, ethnicity, mental illness, and physically challenged conditions (Campinha-

Vol. 7, No. 4

Journal of the American Psychiatric Nurses Association

Bacote, 1998; Leininger, 1995; Warren, 1999). Anthony’s (1993) ideas formed the basis of the recovery component of the model. Recovery is the process by which the client—the individual—reowns his or her sense of self as a person who has strengths, abilities, options, and possibilities, despite having a mental illness. In addition, there are certain qualities that providers and systems should develop and use that support a consumer’s recovery process; these include empathy, affirmation, encouragement, and acceptance (Anthony, 1993). Literature Review A review of the literature revealed little about medication monitoring, symptomatology, and cultural factors as they apply to consumers in public mental health systems. Studies tend to focus on issues surrounding medication compliance (Binder, McNiel, & Sandberg, 1998; Cramer & Rosenheck, 1998; Fenton, Blyler, & Heinssen, 1997), cultural differences in prescribing psychotropic medications (Frackiewicz, Sramek, Herrera, Kurtz, & Cutler, 1997; Lin et al., 1995; Sclar et al., 1998), and physiological responses to antipsychotic medications (Binder et al., 1998; Lin et al., 1995). Several investigations have also examined persons’ recognition of symptoms, signs of relapse, and self-care strategies. Findings indicate that these variables significantly influence consumers’ ability to monitor and manage symptoms (Baker, 1988; Hamera, Peterson, Young, & Schaumloffel, 1992; McCandlessGlimcher et al., 1986; Novacek & Raskin, 1998; O’Connor, 1991, 1994). In addition, findings suggest that active symptom monitoring is important in preventing symptom relapse. Consumers can be active participants in the development of strategies for managing their symptoms and medications (Baker, 1998; O’Connor, 1991). The literature review also revealed that symptom manifestation and medication monitoring are multiply determined. Several factors, such as stressors associated with environment, interpersonal relationships, and lack of social support, have been shown to influence consumers’ interpretation of symptoms and contribute to their ability to effectively monitor and manage their medications (Lin et al., 1995; O’Connor, 1994). Moreover, cultural factors have been suggested as important mediators of consumers’ psychological and physiological responses to medications (CampinhaBacote, 1998; Lin et al., 1995; Warren, 1999).

Lutz and Warren

• What is the relationship among cultural factors, stressors, moderators, medication monitoring, and psychiatric symptoms in consumers with severe mental disorders (SMD) in a public mental health system? • Are there differences among consumers with SMD from different cultural groups with regard to levels of psychiatric symptomatology and medication monitoring? In addition, the following hypotheses were tested: There will be significant differences in psychiatric symptom levels and medication monitoring between groups of consumers based on age, gender, ethnicity, and diagnostic category. Higher levels of stressors and lower levels of moderators will be associated with higher levels of psychiatric symptoms and ineffective medication monitoring. METHODS Design This study was a cross-sectional, secondary analysis of data from a longitudinal research project. This twopart project was designed to test a model of needs, services, and outcomes and to examine the effects of system change on consumers’ services and needs after the enactment of Ohio’s 1988 Mental Health Act (Amended Substitute Senate Bill 156, 117th Ohio General Assembly, 1988). Descriptions of the project can be found in published reports by Roth and colleagues (1996, 1998). The present study extended the focus of consumers’ services and needs to include issues of cultural factors as they relate to symptomatology and medication monitoring.

Medication compliance seems to imply a passive role for the consumer. In keeping with Anthony’s (1993) ideas on recovery, the investigators chose to focus on medication monitoring rather than medication compliance. Medication compliance seems to imply a passive role for the consumer. Moreover, a compliance-oriented approach does not reflect an understanding of the cultural and individual issues involved in consumers’ interpretation of health education and health care actions (Warren, 1999). Sample

Research Questions and Hypotheses This study addressed the following research questions:

August 2001

The sample for the study was drawn from a larger population of consumers and case managers who are participating in a longitudinal study of consumer

APNA Web site: www.apna.org 117

Lutz and Warren

Journal of the American Psychiatric Nurses Association

Table 1. Correlations among major study variables (N = 199) Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. *p

1

Race Gender 0.073 Age –0.078 Alcohol/drug 0.185‡ abuse Physical 0.067 symptoms Leisure Scale –0.046 IPR help 0.041 negotiating Friends Scale 0.032 Self esteem –0.034 Medication 0.041 management Medication 0.073 independence Symptom –0.003 recognition Depression 0.039 symptoms Anxiety 0.001 symptoms Psychotic 0.060 symptoms

2

3

4

5

6

7

8

9

10

11

12

13

14

0.220§ –0.217‡ –0.233§ 0.120*

0.139†

0.047

–0.041 0.074 –0.189‡ –0.358 –0.117 –0.003 0.042 –0.101

0.020

–0.012 0.116 –0.058 –0.211‡ –0.083 –0.065 –0.087 –0.250 –0.166‡ –0.026 0.029 0.031

0.491 –0.097 0.500 –0.071 0.004 0.371

–0.176 ‡ –0.092 –0.092

0.258 –0.096 –0.010

0.129* –0.032 –0.140†

0.100

0.418 -0.113 –0.122*

0.424 –0.168†

0.027

0.008

0.216‡ –0.111 –0.001

0.173‡

0.174‡

0.083 –0.026

0.206‡

0.399 –0.463

0.201‡ –0.307 –0.557

0.232§

0.061 –0.328

0.073

0.015

0.130*

0.361 –0.333

0.175‡ –0.192‡ –0.434

0.218§

0.073 –0.286

0.785

–0.027 –0.066

0.149†

0.352 –0.331

0.184‡ –0.314 –0.513

0.275

0.151† –0.314

0.820

0.790

< .10. †p < .05. ‡p < .01. §p < .001. p < .0001. IPR, Interpersonal relations.

needs and services. The sample was comprised of 199 consumers with severe and persistent mental disorders who were receiving community-based services in Ohio’s public mental health system. Cultural and demographic characteristics. The cultural and demographic characteristics of the participants are representative of the population of persons with SMD served in Ohio’s public mental health system. Almost one fourth (24%, n = 48) of the sample was comprised of African American, Asian American, Hispanic American, and Native American persons. Slightly more than half of the consumers (58%, n = 115) were female. Most subjects were between 30 and 64 years of age; the average age was 48.5 years. Less than half (45%, n = 89) had completed high school, with 38% (n = 76) completing less than 12 years of education. Median monthly income was approximately $458, and average monthly income was approximately $555. Most consumers (78%, n = 155) were unemployed and receiving public assistance. The majority (84%, n = 167) were single (36% never married; 47% separated, divorced, or widowed; and 1% living together).

118 APNA Web site: www.apna.org

Primary diagnoses and level of functioning. Diagnoses and level of functioning were determined according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994). Almost two thirds (65%, n = 129) of the participants had Axis I diagnoses of schizophrenia and other psychoses. Within this group, most were European Americans, female, and between 30 and 65 years of age. About one third (n = 65) of the consumers had Axis I diagnoses of major depression and other mood disorders. Within this group, almost twice as many women had diagnoses of mood disorders as men, which is consistent with the 2:1 ratio for depression and mood disorders reported in the epidemiological literature. A small number (n = 5) had Axis I diagnoses of anxiety disorders. Examination of Global Assessment of Functioning scores (American Psychiatric Association, 1994) revealed that a small number (5%, n = 10) of participants had no symptoms or were experiencing transient symptoms with no impairment in functioning. About one fourth (approximately 28%, n = 56) had

Vol. 7, No. 4

Journal of the American Psychiatric Nurses Association

minimal to mild levels of symptoms without impairment in functioning. The remaining consumers were experiencing more severe symptoms and some degree of impairment in their functioning. Approximately 43% (n = 86) had moderate to major impairments in functioning and about 6% (n = 12) were unable to function without supervision. Measurement and Data Collection Procedures Data for the longitudinal study of consumer needs and service outcomes were collected by using interviews and questionnaires. Consumer interviews were conducted by trained field interviewers and lasted between 1 and 1.5 hours. Most of the interviews occurred in the consumer’s home without family members, friends, or other persons present. Questions addressed services they received, their service needs, relationships with family, friends, and mental health professionals, and mental health outcomes. Case managers completed a questionnaire about the participant’s level of functioning, symptomatology, needs, and services. Questions were also included in the interviews and questionnaires to assess physical health, interpersonal relationships, medication monitoring, and the ability to recognize warning signs and take action on symptoms. The Brief Symptom Inventory (Derogatis & Melisaratos, 1983) and the Symptom Checklist-90Revised (Derogatis, 1983) were used to assess symptoms. The Quality of Life Scale (Lehman, 1988) was used to determine consumers’ perceptions of the quality of different aspects of their lives, including friendships, leisure activities, and family relationships. Self esteem was assessed by using Rosenberg’s (1979) Self-Esteem Scale. The Uniform Client Data Instrument was used to assess basic, social, and community living skills (Widlak, McKee, Greenberg, & Greenley, 1992). A complete description of the instruments and data collection procedures is available in an article by Roth et al. (1998). Classification of psychotropic medications. After reviewing several drug classifications in the pharmaceutical and nursing pharmacology literature (Glod, 1998; Haber et al., 1998; Keltner, 1999; Putzantian & Stimmel, 1997; Stuart & Laraia, 1998), the investigators developed a classification system that incorporated drugs most commonly used in the treatment of mental health disorders. For the purposes of this study, the following primary classifications were used: antidepressants, antimaniacs, antipsychotics, antidyskinetics, anxiolytics, and sedative-hypnotics. Data Analysis Multivariate analyses of variance (MANOVA) and univariate analyses of variance (ANOVA) were con-

August 2001

Lutz and Warren

ducted to determine differences in psychiatric symptoms and medication monitoring according to race, gender, age, and diagnostic category. Correlational analyses were used to explore interrelationships among the major study variables. In addition, hierarchical multiple regression analyses with sets were used to identify the relative contribution of the study variables in explaining psychiatric symptomatology. This analytic procedure is recommended for studies that contain multiple independent variables; the approach identifies the unique contribution of each set of variables to the criterion, taking into account the interrelationships among the independent variables (Cohen & Cohen, 1983; Munro & Page, 1993). Six sets of independent variables that represented certain stressors and moderators in the Recovery and Monitoring Model (Figure) were entered first into the hierarchy. Sets of interaction terms, comprised of cultural factors and medication-monitoring variables, were entered sequentially at the last step in the hierarchy. A general F test was used to test significant changes in R2 in the hierarchy of analyses (Cohen & Cohen, 1983; Munro & Page, 1993).

The most frequently prescribed medications, in descending order, were antipsychotics, antidyskinetics, and antidepressants. RESULTS Medication Profile The total number of prescriptions was 470, with an average of 2.3 psychotropic medications per person (SD, 1.06). Most participants were taking two to three different kinds of medications (range, 1-5). The most frequently prescribed medications, in descending order, were antipsychotics, antidyskinetics, and antidepressants. On average, European Americans received more medications than African Americans, consumers 45 years and older received more medications than consumers under the age of 45, and women received more medications than men. The most frequently prescribed antipsychotics were Haldol (haloperidol, n = 37), Risperdal (risperidone, n = 31), and Prolixin (fluphenazine, n = 30). About 28% (n = 132) of the prescriptions for antipsychotics were written for atypicals, such as Clozaril and Risperdal. Cogentin (benztropine, n = 75) was the most frequently prescribed antidyskinetic, and Prozac (fluoxetine, n = 14), Desyrel (trazadone HCL, n = 13), and Paxil (paroxetine, n = 12) were the most frequently prescribed antidepressants.

APNA Web site: www.apna.org 119

Lutz and Warren

Journal of the American Psychiatric Nurses Association

Table 2. Hierarchical regressions: Psychiatric symptomatology (N = 199) Depression Sets Set A: Cultural factors Race Gender Age Set B: Physiological stressors Alcohol/drug abuse Interference with functioning Set C: Environmental stressors Quality of leisure Set D: Interpersonal relations Help negotiating problems Quality of friendships Set E: Personal competencies Self esteem Set F: Medication monitoring Help managing medications Independence taking medications Recognition of symptoms Set G: Interaction terms Age × independence

R2

R2

increase

Anxiety β

0.01

R2

R2

increase

0.194‡

0.149

0.094‡

0.144‡

0.061‡

0.046‡

0.309

0.045‡

0.075‡

0.354

0.019‡

0.037‡

0.250

0.018

–0.020 0.072 –0.010 0.373

0.123‡

0.045†

0.428

0.055‡

–0.409

0.117 –0.597† 0.179‡ 0.382

0.580†

0.187

–0.307

0.111* –0.533† –0.188‡ 0.532

0.028 0.249

0.136* 0.119

–0.362 0.513

0.142‡

–0.129 0.234

0.109‡

0.150

0.039‡

0.176‡ 0.055 0.468

–0.010 –0.062 –0.483

0.068 0.254 0.188

β

0.008

–0.190‡ 0.359

R2 increase

–0.081 0.041 –0.351†

0.131† 0.236 0.298

β

0.005 –0.053 0.059 –0.309†

0.204

Psychoticism R2

0.028‡

0.138† –0.678‡ –0.176‡ 0.472

0.714§

0.044‡ 0.877

taking medications *p < .10. †p < .05. ‡p < .01. §p < .001. p < .0001.

Tests of Hypotheses Results of the MANOVAs revealed that there were no overall main effects for race, gender, age, and diagnostic category, and no overall interaction effects among the scores for psychiatric symptoms and among the scores for medication monitoring. ANOVA results revealed no significant race, gender, and age differences in consumer reports of psychiatric symptoms (depression, anxiety, psychoticism). Significant differences in psychiatric symptom scores were found for diagnostic category. Consumers with mood disorders reported higher levels of anxiety (F [1,156] = 8.244, p < .01) and depression (F [1,156] = 10.361, p < .01) than did consumers with psychotic disorders. With regard to medication-monitoring scores, significant differences were found for race, gender, and diagnostic category. African American consumers reported less independence in taking medications than did European American consumers (F [1,166] = 4.00, p < .05). Men reported needing more help in managing medications (F [1,170] = 3.98, p < .05) and less independence in taking medications than women

120 APNA Web site: www.apna.org

(F [1,170] = 4.63, p < .05). Persons with psychoses reported less independence in taking medications than persons with mood disorders (F [1,156] = 7.11, p < .01). In addition, persons with psychoses tended to report needing more help with managing medications (F [1,156] = 2.84, p < .10). These results provide partial support for the first hypothesis. As shown in Table 1, psychiatric symptoms were significantly related to the following variables: physiological, environmental, and interpersonal relationship stressors, personal competencies, and medication monitoring. That is, consumers with higher levels of psychiatric symptoms (depression, anxiety, and psychoticism), as compared with persons with lower symptom levels, were more likely to report that physical symptoms interfered with their functioning, to indicate lower quality in their friendships, leisure time, and activities, and to have lower self-esteem. They also reported needing more help negotiating problems with others, needing more help managing medications, and having more difficulty with recognition of symptoms. Persons with higher levels of psychoticism were less independent in taking their medications.

Vol. 7, No. 4

Journal of the American Psychiatric Nurses Association

Cultural factors were significantly related to physiological stressors and medication monitoring. European Americans, women, and older respondents were less likely than African Americans, men, and younger participants to have abused alcohol and drugs. Men were more likely than women to report needing more help in managing medications and to report less independence in taking medications. Older consumers were more likely than younger ones to indicate that physical symptoms interfered with their functioning. The pattern of these results provided initial support for the second hypothesis. The results of the hierarchical regression analyses, which are presented in Table 2, provide additional support for the second hypothesis. The regression model, excluding interaction terms, explained 51% of the variance in depression, 35% of the variance in anxiety, and 43% of the variance in psychoticism. The pattern of results was similar within each regression. That is, set A (cultural factors) was not significant when entered into the hierarchy, whereas sets B through F made significant, unique contributions to the variance in depression, anxiety, and psychoticism. The amount of additional variance contributed by Sets B through F ranged from about 5% to 19% for depression, about 5% to 14% for anxiety, and about 2% to 14% for psychoticism. The set of medication-monitoring variables (F) significantly explained 4% to 5% additional variance in psychiatric symptoms, over and above that already accounted for by the variables in each model. One interaction term (Set G) was significant, age by independence in taking medications. Thus, it appears that the effect of independence in taking medications on psychiatric symptoms is a function of age. This finding suggests that older consumers are less likely to be independent in taking medications when they have higher levels of depression, anxiety, and psychoticism. β weights (Table 2) were significant for all three psychiatric symptoms on the following: age, physical symptoms interfering with functioning, self esteem, and independence in taking medications. The weights for alcohol/drug abuse, leisure quality, and help negotiating problems were significant only for depression. The weight for help needed managing medications was significant only for psychoticism. These findings suggest that certain stressors and moderators may be more salient than others in explaining the variance in psychiatric symptoms. It is important to note that the results presented in Table 2 represent the “final, trimmed model” from the regression analyses. The following additional variables were examined but did not contribute statistically to the variance in psychiatric symptoms: consumer ratings of the importance of taking medications, the extent of consumer involvement in medication deci-

August 2001

Lutz and Warren

sions, the extent to which consumers were bothered by side effects of medications, and explanations about the purpose of the medication and its side effects. Even though these variables did not explain significant amounts of variance in this study, they should not be excluded from future studies that examine medication issues. These variables may provide unique insights about symptoms, medication monitoring, and cultural influences in studies with consumers from diverse cultures and/or from different service settings.

Age was found to be a salient cultural characteristic in the explanation of psychiatric symptoms.

DISCUSSION The results from the study contribute to the evolving body of knowledge about the relationship among symptoms, medication issues, cultural influences, and consumers in the public mental health system. The findings also provide insight into biopsychosocial variables that influence consumer outcomes. Age was found to be a salient cultural characteristic in the explanation of psychiatric symptoms. This finding should not be interpreted to mean that race and gender are unimportant. This finding may have been influenced, at least in part, by the fact that the sample tended to be adults who were of middle age and older. Physical and environmental stressors, as well as moderators, contribute important information to nurses’ understanding of how psychiatric symptoms are manifested in consumers. The following stressors and moderators were found to be particularly meaningful in understanding psychiatric symptomatology: alcohol and drug abuse, physical symptoms interfering with functioning, quality of leisure time and activities, help negotiating problems with others, and self esteem. Consideration of medication monitoring is essential to nurses’ understanding of the manifestation of psychiatric symptoms in consumers. Salient aspects include help needed managing medications, independence in taking medications, and recognition of symptoms. Components of the Recovery and Monitoring Model (Figure 1) were found to be relevant and applicable to consumers in the public mental health system. The findings indicated that certain variables provide meaningful information about the relationship among psychiatric symptoms, medication monitoring, stressors, and moderators. Although the recovery component of the model was not directly examined in this study, the

APNA Web site: www.apna.org 121

Lutz and Warren

Journal of the American Psychiatric Nurses Association

next phase of data collection includes an assessment of the consumers’ perception of their recovery, which will enable examination of the relationship among symptomatology, recovery, and medication monitoring.

It is vital for PMH nurses to be culturally competent in their particular area of practice, education, or research.

IMPLICATIONS The results of this study have important implications for best practices within PMH nursing. The implications discussed below are not intended to be an exhaustive or complete list of nursing strategies. However, these implications are consistent with and complement nationally recognized guidelines for treatment of serious disabling disorders (American Nurses Association Task Force, 1994; Depression Guideline Panel, 1994; McEvoy et al., 1996). Results of the study reflect the importance that culture has upon consumers’ attitudes and perceptions of their mental health. Therefore, it is vital for PMH nurses to be culturally competent in their particular area of practice, education, or research. Cultural competence should be the cornerstone for assessing, planning, implementing, and evaluating clinical interventions with consumers. The set of medication-monitoring variables explained significant, unique amounts of variance in psychiatric symptoms—4% to 5% additional variance in depression, anxiety, and psychoticism. In addition, some medication-monitoring variables, such as teaching about medications and side effects, importance of taking medications, and involvement in medication decisions, failed to reach statistical significance when entered into the regression hierarchy. Together, these findings suggest that certain aspects of medication monitoring may be more salient to consumers than other aspects. Thus, one implication for nursing practice is to determine what individual consumers believe is important to them with regard to medication monitoring before developing specific interventions for them to monitor medications. This includes discovering the consumers’ cultural beliefs regarding their psychiatric symptoms, medication use, and alternative, non-Western health care. It is important for nurses to know this cultural information about themselves, their consumers, and the consumer’s significant others. With this foundation, nurses and consumers can work together to design appropriate strategies to assist or enhance the individual consumer’s ability to manage medications.

122 APNA Web site: www.apna.org

Environmental and interpersonal relationship stressors explained significant amounts of variance in psychiatric symptoms along with physiological stressors, personal competencies, and medication monitoring. These findings point to the importance of healthy support systems for consumers with SMD, which may include biological or consumer-defined family members, significant others, peers, church groups, self-help groups, social groups, and social organizations. Support systems grounded in the consumer’s culture may be helpful in teaching or assisting a consumer with the development of effective coping skills and strategies. More specifically, they may be able to offer culturally appropriate ways for consumers to recognize psychiatric symptoms, deal with physical symptoms that may interfere with functioning, effectively manage their medications, and become independent in monitoring their medications. Results from this study also indicate that salient components of medication monitoring for consumers include assistance with managing medications, independence in taking medications, and recognizing symptoms. Therefore, these variables are important ones to integrate into culturally competent protocols, interventions, and strategies with consumers. Consumers’ recognition of their symptoms is grounded in their cultural beliefs and perspectives that influence their “cultural compliance” in taking medications, their decisions about medications, and their views concerning the role of alternative treatments in the management of their symptoms (Campinha-Bacote, 1998; Lin et al., 1995; Purnell & Paulanka, 1998; Warren, 1999). For example, persons from African, Hispanic, and/or Native American cultures may embrace the idea that they are joined with their ancestors and the spiritual world. This cultural belief may alter how men and women of different ages perceive and interpret symptoms associated with psychiatric disorders. For example, their belief that they are joined to the spirit world may cause them to hear and speak to these ancestors. This perspective may be misinterpreted by culturally incompetent nurses as hallucinations or delusions, whether or not the consumer is symptomatic. However, culturally competent nurses can draw upon the broader perspective of the consumer’s healthy reference group (i.e., significant others) to assess and interpret these “symptoms.” With this information, nurses can help the consumer to differentiate cultural behaviors from psychiatric symptomatology. Cultural negotiation and repatterning are important strategies for maintaining consumers’ cultural beliefs (Leininger, 1995). For example, some persons from the Hispanic culture believe in the idea of “hot and cold” treatments. Certain medications and foods are not compatible and should not be consumed at the same time. The consumer, or significant others in the consumer’s

Vol. 7, No. 4

Journal of the American Psychiatric Nurses Association

reference group, can inform the nurse as to which medications and foods are incompatible. This information can then be used to develop a plan of care and to assist a consumer with decisions about which medications to use and how to monitor them. In addition, the nurse may need to be an advocate for the consumer as they (i.e., consumer and nurse) negotiate with other health care professionals regarding decisions about the consumer’s medications. The nurse may also need to be an advocate for the consumer as he or she moves from one system of care to another. These culturally competent strategies can be incorporated into a comprehensive plan of care and may contribute to the development of a sense of empowerment within the individual, which is an integral part of the consumer’s recovery process. In summary, this study began with an interest in the relationship among cultural factors, medication monitoring, and psychiatric symptomatology in consumers within the public mental health system. O’Connor’s vulnerability-stress framework was used to guide the initial conceptualization of the study. Variables in her model were redefined and expanded to better depict the importance of cultural patterns and influences of the consumers within a public mental health system. The study provided an opportunity to begin to examine certain variables within the Recovery and Monitoring Model. The findings reveal that the model is most relevant and applicable to consumers of public mental health services and warrants further investigation. The model has considerable utility for PMH nurses involved in research, education, and clinical practice.

REFERENCES American Nurses Association Task Force on Psychopharmacology 1992-1994. (1994). Psychiatric mental health nursing psychopharmacology project (PMH—13 10 M 594). Washington, DC: American Nurses Publishing. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Nurses Association. (1997). Report of the APNA Congress on Advanced Practice in Psychiatric Nursing. Washington, DC: Author. Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Innovations & Research, 1(3), 17-24. Baker, C. (1998). Detecting early signs of relapse. Current Approaches to Psychoses, 7(May), 8-9. Binder, R. L., McNiel, D. E., & Sandberg, B. A. (1998). A naturalistic study of clinical use of risperidone. Psychiatric Services, 49, 524528. Campinha-Bacote, J. (1998). The process of cultural competence in the delivery of healthcare services: A culturally competent model of care. (3rd ed.). Cincinnati, OH: Author. Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.

August 2001

Lutz and Warren

Cramer, J. A., & Rosenheck, R. (1998). Compliance with medication regimes for mental and physical disorders. Psychiatric Services, 49, 196-201. Depression Guideline Panel. (1993). Depression in primary care: Vol. I diagnosis and detection (Clinical Practice Guideline No. 5, AHCPR Publication No. 93-0550). Rockville, MD: Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Derogatis, L. R. (1983). SCL-90 administration, scoring & procedures manual — I. Baltimore, MD: Johns Hopkins University School of Medicine. Derogatis, L. R., & Melisaratos, N. (1983). The Brief Symptom Inventory: An introductory report. Psychological Medicine, 13, 595-605. Fenton, W. S., Blyler, C. R., & Heinssen, R. K. (1997). Determinants of medication compliance in schizophrenia: Empirical and clinical findings. Schizophrenia Bulletin, 23, 637-651. Frackiewicz, E. G., Sramek, J. J., Herrera, J. M., Kurtz, N. M., & Cutler, N. R. (1997). Ethnicity and antipsychotic response. Annals of Pharmacotherapy, 31, 1360-1368. Glod, C. A., & Levy, S. (1998). Psychopharmacology. In C. A. Glod (Ed.), Contemporary psychiatric-mental health nursing (pp. 92126). Philadelphia: Davis. Haber, J., Krainovich-Miller, B., McMahon, A. L., & Price-Hoskins, P. (1997). Psychopharmacology. In J. Haber, B. Krainovich-Miller, A. L. McMahon, & P. Price-Hoskins (Eds.), Comprehensive psychiatric nursing (5th ed.) (pp. 261-295). St. Louis, MO: Mosby. Hamera, E. K., Peterson, K. A., Young, L. M., & Schaumloffel, M. M. (1992). Symptom monitoring in schizophrenia: Potential for enhancing self-care. Archives of Psychiatric Nursing, 6, 324-330. Keltner, N. L. (1999). Introduction to psychotropic drugs. In N. L. Keltner, L. H. Schwecke, & C. E. Bostrom (Eds.), Psychiatric nursing (3rd ed., pp. 199-308). St. Louis, MO: Mosby. Leininger, M. (1995). Transcultural nursing: Concepts, theories, and practices. New York: McGraw-Hill. Lehman, A. F. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning, 11, 51-62. Lin, K. M., Poland, R. E., & Anderson, D. (1995). Psychopharmacology, ethnicity and culture. Transcultural Psychiatric Research Review, 32, 3-41. McCandless-Glimcher, L., McKnight, S., Hamera, E., Smith, B. L., Peterson, K. A., & Plumlee, A. A. (1986). Use of symptoms by schizophrenics to monitor and regulate their illness. Hospital and Community Psychiatry, 37, 929-933. McEvoy, J. P., Weiden, P. J., Smith, T. E., Carpenter, D., Kahn, D. A., & Frances, A. (1996). The expert consensus guidelines series: Treatment of schizophrenia. Journal of Clinical Psychiatry, 57(Suppl. 12B), 1-58. Munro, B. H., & Page, E. B. (1993). Statistical methods for health care research (2nd ed.). Philadelphia: Lippincott. Novacek, J., & Raskin, R. (1998). Recognition of warning signs: A consideration for cost effective of severe mental illness. Psychiatric Services, 49, 376-378. O’Connor, F. W. (1991). Symptom monitoring for relapse prevention in schizophrenia. Archives of Psychiatric Nursing, 5, 193-201. O’Connor, F. W. (1994). A vulnerability-stress framework for evaluating clinical interventions in schizophrenia. Image: Journal of Nursing Scholarship, 26, 231-237. Purnell, L., & Paulanka, B. J. (1998). Transcultural health care: A culturally competent approach. Philadelphia: Davis.

APNA Web site: www.apna.org 123

Lutz and Warren

Journal of the American Psychiatric Nurses Association

Putzantian, T., & Stimmel, G. L. (1997). 1997 Review of psychotropic drugs. Research Triangle Park, NC: Glaxo-Wellcome, Inc. Rosenberg, M. (1979). Rosenberg Self-Esteem Scale. In M. Rosenberg (Ed.), Conceiving the self (Appendix A). New York: Basic Books. Roth, D., Crane-Ross, D., Doklovic, S., Vercellini, J., Burns, G., Frazier, M., & Lauber, B. (1996). A longitudinal study of mental health services and consumer outcomes in a changing system. In D. Roth (Ed.), New Research in Mental Health, 12 (pp. 184-197). Columbus, OH: Ohio Department of Mental Health. Roth, D., Crane-Ross, D., Hannon, M., Cusick, G., & Doklovic, S. (1998). The longitudinal study of consumers with severe mental disabilities: Services, needs, relationships and outcomes. In D. Roth (Ed.), New Research in Mental Health, 13 (pp. 104-116). Columbus, OH: Ohio Department of Mental Health.

Sclar, D. A., Robison, L. M., Skaer, T. L., Dickson, W. M., Kozma, C. M., & Reeder, C. E. (1998). A comparison of Blacks and Whites in a medicaid population. Clinical Drug Investigation, 16(2), 135-140. Available at: http://www.medscape.com/adis/CDI/ 1998/v16.no2/cdi1602.04.scla/cdi1602.04.scla.01.html Stuart, G. W., & Laraia, M. T. (1998). Stuart and Sundeen’s principles & practice of psychiatric nursing. St. Louis, MO: Mosby. Warren, B. J. (1999). Cultural competence in psychiatric nursing: An interlocking paradigm approach. In N. L. Keltner, L. H. Schwecke, & C. E. Bostrom (Eds.), Psychiatric nursing (3rd ed.). St. Louis, MO: Mosby. Widlak, P. A., McKee, D., Greenberg, D. R., & Greenley, J. R. (1992). An assessment of Client Function Scale in the Uniform Client Data Instrument (UCDI). Psychosocial Rehabilitation Journal, 15(4), 19-35.

Intent to Submit Journal of the American Psychiatric Nurses Association Nikki S. Polis, RN, PhD University MacDonald Women’s Hospital Mail Stop: MAC 5033 11100 Euclid Ave. Cleveland, OH 44106 If you would like to have a manuscript reviewed for possible publication, photocopy this form and send it to the Journal of the American Psychiatric Nurses Association. We’ll be happy to get in touch with you about your article or column idea. ❏ I would like you to consider my manuscript for possible publication. Subject __________________________________________________________________________________ I will send my manuscript by__________(date). ❏ I would like to contribute to one of the following columns: ❏ Book Review ❏ Dialogue ❏ Interview ❏ Policy & Politics ❏ Briefings ❏ Guest Editorial ❏ Point of View ❏ Psychobiology Perspectives More information about my column submission: ______________________________________________ _________________________________________________________________________________________ Name ______________________________________________________________________________________ Title________________________________________________________________________________________ Employer __________________________________________________________________________________ Work phone ________________________________________________________________________________ E-mail address ______________________________________________________________________________ Home address ______________________________________________________________________________ Home phone ________________________________________________________________________________ See Information for Authors in the beginning of every issue for details on submission, the peer review process, and preparation specifications.

124 APNA Web site: www.apna.org

Vol. 7, No. 4