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1.  A prospective study of the trajectories of clinical insight, affective symptoms, and cognitive ability in bipolar disorder 
Background
Clinical insight in bipolar disorder is associated with treatment adherence and psychosocial outcome. The short-term dynamics of clinical insight in relationship to symptoms and cognitive abilities are unknown.
Methods
In a prospective observational study, a total of 106 outpatients with bipolar disorder I or II were assessed at baseline, 6 weeks, 12 weeks, and 26 weeks. Participants were administered a comprehensive neuropsychological battery, clinical ratings of manic and depressive symptom severity, and self-reported clinical insight. Lagged correlations and linear mixed-effects models were used to determine the temporal associations between symptoms and insight, as well as the moderating influence of global cognitive abilities.
Results
At baseline, insight was modestly correlated with severity of manic symptoms, but not with depressive symptoms or cognitive abilities. Insight and depressive symptoms fluctuated to approximately the same extent over time. Both lagged correlations and mixed effects models with lagged effects indicated that the severity of manic symptoms predicted worse insight at later assessments, whereas the converse was not significant. There were no direct or moderating influences of global cognitive abilities.
Limitations
Our sample size was modest, and included relatively psychiatrically stable outpatients, followed for a six month period. Our results may not generalize to acutely symptomatic patients followed over a longer period.
Conclusions
Clinical insight varies substantially over time within patients with bipolar disorder. Impaired insight in bipolar disorder is more likely to follow than to precede manic symptoms.
doi:10.1016/j.jad.2013.09.020
PMCID: PMC4011138  PMID: 24200153
Bipolar disorder; insight; neuropsychology; depression
2.  Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women 
Objectives
To determine if measures of successful-aging are associated with sexual activity, satisfaction, and function in older post-menopausal women.
Design
Cross-sectional study using self-report surveys; analyses include chi-square and t-tests and multiple linear regression analyses.
Setting
Community-dwelling older post-menopausal women in the greater San Diego Region.
Participants
1,235 community-dwelling women aged 60-89 years participating at the San Diego site of the Women's Health Initiative.
Measurements
Demographics and self-report measures of sexual activity, function, and satisfaction and successful aging.
Results
Sexual activity and functioning (desire, arousal, vaginal tightness, use of lubricants, and ability to climax) were negatively associated with age, as were physical and mental health. In contrast, sexual satisfaction and self-rated successful aging and quality of life remained unchanged across age groups. Successful aging measures were positively associated with sexual measures, especially self-rated quality of life and sexual satisfaction.
Conclusions
Self-rated successful aging, quality of life, and sexual satisfaction appear to be stable in the face of declines in physical health, some cognitive abilities, and sexual activity and function and are positively associated with each other across ages 60-89 years.
doi:10.1111/j.1532-5415.2011.03495.x
PMCID: PMC4151627  PMID: 21797827
Sexual Activity; Sexual Satisfaction; Sexual Function; Post-menopausal Women; Self-Rated Successful aging
3.  When Functional Capacity and Real-World Functioning Converge: The Role of Self-Efficacy 
Schizophrenia Bulletin  2012;39(4):908-916.
Although functional capacity is typically diminished, there is substantial heterogeneity in functional outcomes in schizophrenia. Motivational factors likely play a significant role in bridging the capacity-to-functioning gap. Self-efficacy theory suggests that although some individuals may have the capacity to perform functional behaviors, they may or may not have confidence they can successfully perform these behaviors in real-world settings. We hypothesized that the relationship between functional capacity and real-world functioning would be moderated by the individual’s self-efficacy in a sample of 97 middle-aged and older adults with schizophrenia (mean age = 50.9 ± 6.5 years). Functional capacity was measured using the Brief UCSD Performance-based Skills Assessment (UPSA-B), self-efficacy with the Revised Self-Efficacy Scale, and Daily Functioning via the Specific Level of Functioning (SLOF) scale and self-report measures. Results indicated that when self-efficacy was low, the relationship between UPSA-B and SLOF scores was not significant (P = .727). However, when self efficacy was high, UPSA-B scores were significantly related to SLOF scores (P = .020). Similar results were observed for self-reported social and work functioning. These results suggest that motivational processes (ie, self-efficacy) may aid in understanding why some individuals have the capacity to function well but do not translate this capacity into real-world functioning. Furthermore, while improvement in capacity may be necessary for improved functioning in this population, it may not be sufficient when motivation is absent.
doi:10.1093/schbul/sbs004
PMCID: PMC3686440  PMID: 22328642
functioning; psychosis; motivation; control; recovery
4.  Summer Research Training for Medical Students: Impact on Research Self-Efficacy 
Clinical and translational science  2013;6(6):10.1111/cts.12062.
There is a well documented shortage of physician researchers, and numerous training programs have been launched to facilitate development of new physician scientists. Short-term research training programs are the most practical form of research exposure for most medical students, and the summer between their first and second years of medical school is generally the longest period they can devote solely to research. The goal of short-term training programs is to whet the students’ appetite for research and spark their interest in the field. Relatively little research has been done to test the effectiveness of short-term research training programs. In an effort to examine short-term effects of three different NIH-funded summer research training programs for medical students, we assessed the trainees’ (N=75) research self-efficacy prior to and after the programs using an 11-item scale. These hands-on training programs combined experiential, didactic, and mentoring elements. The students demonstrated a significant increase in their self-efficacy for research. Trainees’ gender, ranking of their school, type of research, and specific content of research project did not predict improvement. Effect sizes for different types of items on the scale varied, with the largest gain seen in research methodology and communication of study findings.
doi:10.1111/cts.12062
PMCID: PMC3868994  PMID: 24330695
5.  Is Late-Onset Schizophrenia a Subtype of Schizophrenia? 
Acta psychiatrica Scandinavica  2010;122(5):414-426.
Objective
To determine whether late-onset schizophrenia (LOS, onset after age 40) should be considered a distinct subtype of schizophrenia.
Method
Participants included 359 normal comparison subjects (NCs) and 854 schizophrenia outpatients age > 40 (110 LOS, 744 early-onset schizophrenia or EOS). Assessments included standardized measures of psychopathology, neurocognition, and functioning.
Results
EOS and LOS groups differed from NCs on all measures of psychopathology and functioning, and most cognitive tests. EOS and LOS groups had similar education, severity of depressive, negative, and deficit symptoms, crystallized knowledge, and auditory working memory, but LOS patients included more women and married individuals, had less severe positive symptoms and general psychopathology, and better processing speed, abstraction, verbal memory, and everyday functioning, and were on lower antipsychotic doses. Most EOS-LOS differences remained significant after adjusting for age, gender, severity of negative or deficit symptoms, and duration of illness.
Conclusions
LOS should be considered a subtype of schizophrenia.
doi:10.1111/j.1600-0447.2010.01552.x
PMCID: PMC3939834  PMID: 20199491
Schizophrenia; aging; cognition; negative symptoms; quality of life; positive symptoms
6.  Subthreshold Depression and Successful Aging in Older Women 
Objectives
Subthreshold Depression (StD) is common in older adults and is associated with poor self-rated health. However, the impact of StD on broader indicators of successful aging, such as positive psychological constructs, cognitive functioning, or quality of well-being, has not been assessed. We compared persons with scores above and below a predetermined threshold on the Center for Epidemiological Studies Scale for Depression (CESD) to non-depressed persons (ND) on measures of multiple domains associated with successful aging.
Design
Cross sectional survey-based psychological assessments.
Participants
1,979 community-dwelling older women participating in the Women’s Health Initiative study.
Measurements
ND was defined as a CESD score below 8, StD as a score between 8 and 15, and CESD Depression (CD) as a score of 16 or above. The study questionnaire consisted of multiple self-reported measures of positive psychological functioning (e.g., optimism, resilience), cognitive functioning and complaints, and quality of well-being. We also obtained a history of diagnosis, treatment, and hospitalization related to mental health problems.
Results
20.2% of women met CES-D criteria for StD and 7% for CD. Women with StD had worse self-rated successful aging, worse physical and emotional functioning, lower optimism, more negative attitudes toward aging, lower personal mastery and self-efficacy, and greater anxiety and hostility than ND women, but scored better on all these measures than women with CD. StD subjects also had higher self-reported rates of previous diagnosis, treatment, and hospitalization for mental health problems than the ND group. StD subjects with depressed mood and/or anhedonia were largely similar to those without these symptoms.
Conclusions
Mild-moderate levels of depressive symptoms that likely fall under a general category of StD were common, and were associated with worse functioning on virtually every component of successful aging that we examined. StD represents a clinical entity that may affect the longitudinal course of successful aging for large numbers of persons and is a potential target for clinical intervention.
doi:10.1097/JGP.0b013e3181b7f10e
PMCID: PMC3937985  PMID: 20224518
7.  Older Age is Associated with More Successful Aging: Role of Resilience and Depression 
The American journal of psychiatry  2013;170(2):188-196.
Background
There is growing public health interest in understanding and promoting successful aging. While there has been some exciting empirical work on objective measures of physical health, relatively little published research combines physical, cognitive, and psychological assessments in large, randomly selected, community-based samples to assess self-rated successful aging (SRSA).
Methods
In this Successful AGing Evaluation (SAGE) study, we used a structured multi-cohort design to assess successful aging in 1,006 community-dwelling adults in San Diego County, aged 50–99 years, with over-sampling of people over 80. A modified version of random digit dialing was used to recruit subjects. Evaluations included a 25-minute phone interview followed by a comprehensive mail-in survey of physical, cognitive, and psychological domains, including SRSA (scaled from 1 [lowest] to 10 [highest]) and positive psychological traits.
Results
In our sample with mean age of 77.3 years, the mean SRSA score was 8.2, and older age was associated with higher SRSA (R2 = 0.027), despite worsening physical and cognitive functioning. The best multiple regression model achieved, using all the potential correlates, accounted for 30% of variance in SRSA, and included resilience, depression, physical functioning, and age (entering the regression model in that order).
Conclusions
Resilience and depression had a significant association with SRSA with effect sizes comparable to that for physical health. While no causality can be inferred from cross-sectional data, increasing resilience and reducing depression might have as strong effects on successful aging as reducing physical disability, suggesting an important role for psychiatry in promoting successful aging.
doi:10.1176/appi.ajp.2012.12030386
PMCID: PMC3593664  PMID: 23223917
Aging; Resilience; Optimism; Depression; Cognition; Disability
8.  Characterizing Trajectories of Cognitive Functioning in Older Adults with Schizophrenia: Does Method Matter? 
Schizophrenia research  2012;143(1):90-96.
Background
Heterogeneity in clinical outcomes may be caused by factors working at multiple levels, e.g., between groups, between subjects, or within subjects over time. A more nuanced assessment of differences in variation among schizophrenia patients and between patients and healthy comparison subjects can clarify etiology and even facilitate the identification of patient subtypes with common neuropathology and clinical course.
Methods
We compared trajectories (mean duration 3.5 years) of cognitive impairments in a sample of 201 community-dwelling schizophrenia (SCZ) patients (aged 40–100 years) with 67 healthy comparison (HC) subjects. We employed growth mixture models to discover subclasses with more homogenous between-subject variation in cognitive trajectories. Post hoc analyses determined factors associated with class membership and class-specific correlates of cognitive trajectories.
Results
Three latent classes were indicated: Class 1 (85% HC and 50% SCZ) exhibited relatively high and stable trajectories of cognition, Class 2 (15% HC and 40% SCZ) exhibited lower, modestly declining trajectories, and Class 3 (10% SCZ) exhibited lower, more rapidly declining trajectories. Within the patient group, membership in Classes 2–3 was associated with worse negative symptoms and living in a board and care facility.
Discussion
These results bridge the gap between schizophrenia studies demonstrating cognitive decline and those demonstrating stability. Moreover, a finer-grained characterization of heterogeneity in cognitive trajectories has practical implications for interventions and for case management of patients who show accelerated cognitive decline. Such a characterization requires study designs and analyses sensitive to between- and within-patient heterogeneity in outcomes.
doi:10.1016/j.schres.2012.10.033
PMCID: PMC3540183  PMID: 23218560
Late-Life Schizophrenia; Cognition; Trajectories; Heterogeneity; Growth Mixture Models
9.  Preliminary Evidence for Feasibility, Use, and Acceptability of Individualized Texting for Adherence Building for Antiretroviral Adherence and Substance Use Assessment among HIV-Infected Methamphetamine Users 
AIDS Research and Treatment  2013;2013:585143.
The feasibility, use, and acceptability of text messages to track methamphetamine use and promote antiretroviral treatment (ART) adherence among HIV-infected methamphetamine users was examined. From an ongoing randomized controlled trial, 30-day text response rates of participants assigned to the intervention (individualized texting for adherence building (iTAB), n = 20) were compared to those in the active comparison condition (n = 9). Both groups received daily texts assessing methamphetamine use, and the iTAB group additionally received personalized daily ART adherence reminder texts. Response rate for methamphetamine use texts was 72.9% with methamphetamine use endorsed 14.7% of the time. Text-derived methamphetamine use data was correlated with data from a structured substance use interview covering the same time period (P < 0.05). The iTAB group responded to 69.0% of adherence reminder texts; among those responses, 81.8% endorsed taking ART medication. Standardized feedback questionnaire responses indicated little difficulty with the texts, satisfaction with the study, and beliefs that future text-based interventions would be helpful. Moreover, most participants believed the intervention reduced methamphetamine use and improved adherence. Qualitative feedback regarding the intervention was positive. Future studies will refine and improve iTAB for optimal acceptability and efficacy. This trial is registered with ClinicalTrials.gov NCT01317277.
doi:10.1155/2013/585143
PMCID: PMC3776360  PMID: 24078868
10.  Prediction of Real World Functional Disability in Chronic Mental Disorders: A Comparison of Schizophrenia and Bipolar Disorder 
The American journal of psychiatry  2010;167(9):1116-1124.
OBJECTIVE
Schizophrenia (SZ) and Bipolar Disorder (BD) are associated with multidimensional disability. This study examined differential predictors of functional deficits between the disorders.
METHODS
Community dwelling individuals with SZ (N=161) or BD (N=130) were administered neuropsychological tests, symptom measures, performance-based social and adaptive (i.e., everyday-living skills) functional competence measures, and rated on domains of real-world functioning: 1) Community and Household activities, 2) Work skills, and 3) Interpersonal relationships. We used confirmatory path analysis to find the best fitting models to examine the direct and indirect (as mediated by competence) prediction of the three domains of real-world functioning.
RESULTS
In all models for both groups, neurocognition’s relationship with outcomes was largely mediated by competence. Symptoms were negatively associated with outcomes but unassociated with competence, with the exception of depression, which was a direct and mediated (through social competence) predictor in BD. In both groups, neurocognition was related to Activities directly and through a mediated relationship with adaptive competence. Work Skills were directly and indirectly (through mediation with social competence) predicted by neurocognition in SZ and entirely mediated by adaptive and social competence in BD. Neurocognition was associated with Interpersonal Relationships directly in the SZ group, and mediated by social competence in both groups.
CONCLUSIONS
Although there was greater disability in SZ, neurocognition predicted worse functioning in all outcome domains in both disorders. Our study supports the shared role of neurocognition in BD and SZ in producing disability, with predictive differences between disorders observed in domain-specific effects of symptoms and social and adaptive competence.
doi:10.1176/appi.ajp.2010.09101406
PMCID: PMC3694770  PMID: 20478878
11.  To What Factors Do Rural-Dwelling Hispanics Attribute Depressive Symptoms? 
This study is a retrospective chart review comparing rural-dwelling Caucasian and Hispanic outpatients' attribution of depressive symptoms. Based on the data gathered at intake, Hispanics were more likely to attribute depression to curse/spell and supernatural causes, while Caucasians were more likely to attribute symptoms to hereditary factors or job stress. Among both groups, higher CESD score was associated with problems with significant others or how they got along with others. Among Hispanics, depression severity was additionally associated with problems related to job or finances. Our findings point to a consequential role for clinical inquiry into attributed causes of depressive symptoms.
doi:10.1155/2013/781986
PMCID: PMC3677663  PMID: 23781333
12.  5HTTLPR Short Allele, Resilience and Successful Aging in Older Adults 
Objective
Resilience is proposed as a significant component of successful aging. Young adult carriers of the Serotonin Transporter Polymorphism (5HTTLPR) short(s) allele appear to have reduced resilience to stress. We examined if presence of the short allele was associated with poorer emotional resilience in older adults.
Methods
In a cross-sectional study of 99 healthy, community-dwelling, older adults we determined 5HTTLPR genotype status and administered the Connor-Davidson Resilience Scale and self-reported measures of successful aging, cognition and health.
Results
There was no significant association between the 5HTTLPR s allele and resilience. S allele carriers had worse cognition and self-report ratings of successful aging.
Conclusions
These findings suggest that the impact of the 5HTTLPR s allele on stress-related outcomes may attenuate with older age. However, s allele status appears to be a biomarker of poorer self-rated successful aging, and cognitive performance in older adults.
doi:10.1097/JGP.0b013e31823e2d03
PMCID: PMC3326186  PMID: 22233775
5-HTT; Serotonin transporter polymorphism; Resilience; Stress; Successful Aging; Cognition
13.  Meta-Analysis of the Association Between Cognitive Abilities and Everyday Functioning in Bipolar Disorder 
Bipolar Disorders  2012;14(3):217-226.
Objectives
Neurocognitive deficits are common in bipolar disorder and contribute to functional disability. However, the degree to which general and specific cognitive deficits affect everyday functioning in bipolar disorder is unknown. The goal of this meta-analysis was to examine the magnitude of the effect of specific neurocognitive abilities on everyday functioning in bipolar disorder.
Methods
We conducted a comprehensive meta-analysis of studies that reported associations between performance on objective neuropsychological tasks and everyday functioning among individuals with bipolar disorder. From an initial pool of 486 papers, 22 studies met inclusion criteria, comprising a total of 1344 participants. Correlation coefficients were calculated for 11 cognitive domains and four measurement modalities for functioning. We also examined effect moderators, such as sample age, clinical state, and study design.
Results
The mean Pearson correlation between neurocognitive ability and functioning was 0.27, and was significant for all cognitive domains and varied little by cognitive domain. Correlations varied by methods of everyday functioning assessment, being lower for clinician and self-report than performance-based tasks and real-world milestones such as employment. None of the moderator analyses were significant.
Conclusions
Overall, the strength of association between cognitive ability and everyday functioning in bipolar disorder is strikingly similar to that seen in schizophrenia, with little evidence for differences across cognitive domains. The strength of association differed more so according to functional measurement approach.
doi:10.1111/j.1399-5618.2012.01011.x
PMCID: PMC3396289  PMID: 22548895
Bipolar disorder; disability; quality of life; functioning; neuropsychology; cognition
14.  Age, Affective Experience, and Television Use 
Background
The reasons for the reportedly high use of TV watching among older adults despite its potential negative health consequences are not known.
Purpose
To investigate age differences in time use and affective experience in TV use in a nationally representative sample
Methods
Using an innovative assessment of affective experience in a nationally representative sample, several putative reasons were examined for age-related increases in TV use. A sample of 3982 Americans aged 15–98 years who were assessed using a variant of the Day Reconstruction Method, a survey method for measuring how people experience their lives, was analyzed. To understand age increases in TV use, analyses examined whether older people (1) enjoy TV more, (2) watch TV because it is less stressful than alternatives, or whether (3) TV use related to age differences in demographics, being alone, or life satisfaction. Data were collected in 2006 and analyzed in 2008–2009.
Results
Adults aged >65 years spent threefold more waking time watching TV than young adults. Despite this trend, older people enjoyed TV less, in contrast to stable enjoyment with other leisure activities. Older adults did not seem to experience the same stress buffering effects of watching TV as did young and middle-aged adults. This negative age-associated trend in how TV was experienced was not accounted for by demographic factors or in time spent alone. Greater TV use, but not time spent in other leisure activities, was related to lower life satisfaction.
Conclusions
Older adults watch more TV but enjoy it less than younger people. Awareness of this discrepancy could be useful for those developing interventions to promote reduced sedentary behaviors in older adults.
doi:10.1016/j.amepre.2010.03.020
PMCID: PMC3593658  PMID: 20621265
15.  Older Adults’ Perspectives on Successful Aging: Qualitative Interviews 
OBJECTIVES
Lay perceptions of “successful aging” are important for understanding this multifaceted construct and developing ways to assist older adults to age well. The purpose of this qualitative study was to obtain older adults’ individual perspectives on what constitutes successful aging, along with their views regarding activities and interventions to enhance its likelihood.
METHODS
Qualitative interviews were conducted with 22 community-dwelling adults over age 60. Participants were recruited from retirement communities, a low-income senior housing complex, and a continued learning center in San Diego County. Interview transcripts were analyzed using a “Coding Consensus, Co-occurrence, and Comparison” grounded theory framework.
RESULTS
The mean age of participants was 80 years (range: 64 to 96), with 59% being women. Two primary themes were identified as key to successful aging - i.e., self-acceptance/self-contentment (with sub-themes of realistic self-appraisal, a review of one’s life, and focusing on the present) and engagement with life/self-growth (with sub-themes of novel pursuits, giving to others, social interactions, and positive attitude). A balance between these two constructs appeared critical. A need for interventions that address support systems and personally tailored information to make informed decisions and enhance coping strategies were also emphasized.
CONCLUSIONS
Older adults viewed successful aging as a balance between self-acceptance and self-contentedness on one hand and engagement with life and self-growth in later life on the other. This perspective supports the concept of wisdom as a major contributor to successful aging. Interventions to enhance successful aging may include those that promote productive and social engagement along with effective coping strategies.
PMCID: PMC3593659  PMID: 20593536
Successful aging; Adaptation; Resilience; Qualitative methods; Wisdom
16.  Assessment of medication management ability in middle-aged and older adults with bipolar disorder 
Medication non-adherence is a key clinical concern in bipolar disorder across the lifespan. Cognitive deficits in older adults with bipolar disorder may hinder medication management ability, which, in turn, may lead to non-adherence. Using an innovative performance-based measure of medication management ability, the Medication Management Ability Assessment (MMAA), we compared performance of 29 middle-aged older community dwelling outpatients with bipolar disorder who were clinically stable (mean age=61, sd=11 years; rage 45 to 86) to 59 normal control subjects (NCs) and 219 outpatients with schizophrenia. The MMAA is a role-play task that simulates a medication regimen likely to be encountered by older adults. Within the bipolar group, we examined the relationships of MMAA scores to demographic, psychiatric symptoms severity, and the Dementia Rating Scale scores. The bipolar group made 2.8 times the errors on the MMAA than NCs (Bipolar group =6.2 (sd=5.5) vs. NCs=2.2 (sd=2.5), and did not significantly differ from the schizophrenia group in errors on the MMAA. Errors in the bipolar group were more likely to be in taking too few medications as in taking too many. Within the bipolar group, a significant correlation was seen between MMAA scores and DRS Total Score, but not with age, education, BPRS, HAM-D, number of psychiatric medications, or medical conditions. Among DRS subscales, the Memory Subscale correlated most strongly with MMAA errors. This small cross-sectional study suggests that deficits in medication management ability may be present in later-life bipolar disorder. Neurocognitive deficits may be important in understanding problems with unintentional non-adherence.
doi:10.1097/JCP.0b013e318166dfed
PMCID: PMC3593666  PMID: 18344736
Bipolar disorder; aging; older adults; medication management ability; medication adherence; memory
17.  Perspectives on Schizophrenia Over the Lifespan: A Qualitative Study 
Schizophrenia Bulletin  2010;38(2):295-303.
Longitudinal data suggest heterogeneity in the long-term course of schizophrenia. It is unclear how older adults with schizophrenia perceive changes in their experience of schizophrenia over the lifespan. We interviewed 32 adults aged 50 years and older diagnosed with schizophrenia (mean duration 35 years) about their perceived changes in the symptoms of schizophrenia and functioning over the lifespan. Interview transcripts were analyzed using grounded theory techniques of coding, consensus, co-occurrence, and comparison. The study was conducted by a research partnership involving a multidisciplinary team of academic researchers, community members, and mental health clients engaged in all aspects of study design, interviewing, and analysis and interpretation of data. Results revealed that, in regard to early course of illness, participants experienced confusion about diagnosis, active psychotic symptoms, and withdrawal/losses in social networks. Thereafter, nearly all participants believed that their symptoms had improved, which they attributed to increased skills in self-management of positive symptoms. In contrast to consistency among participants in describing illness course, there was marked heterogeneity in perceptions about functioning. Some participants were in despair about the discrepancy between their current situations and life goals, others were resigned to remain in supported environments, and others working toward functional attainments and optimistic about the future. In conclusion, middle-aged and older adults with schizophrenia believed that their symptoms had improved over their lifespan, yet there was substantial variability among participants in how they perceived their functioning. Functional rehabilitation may need to be tailored to differences in perceptions of capacity for functional improvement.
doi:10.1093/schbul/sbq075
PMCID: PMC3283145  PMID: 20603443
aging; psychosis; disability; qualitative research; quality of life
18.  Psychopathological and Functional Correlates of Behavioral Activation and Avoidance in Schizophrenia 
Behavioral activation and avoidance are well studied in depression, yet the relationship of these constructs to symptoms, cognitive ability and functioning in schizophrenia is poorly understood. In a sample of 73 middle-aged and older outpatients with schizophrenia (mean age=50.3, sd=6.3), we examined the relationship of the Activation and Avoidance subscales of the Behavioral Activation for Depression Scale with measures of psychopathology (Positive and Negative Symptoms, Depression), global cognitive ability, and global cognitive ability, and functioning (observer-rated, performance-based, and subjective functioning). Neither activation nor avoidance related to sociodemographic variables, age of onset, or anti-psychotic dose. Although activation and avoidance were significantly inter-correlated, only behavioral activation was significantly associated with depression and subjective functioning, whereas only avoidance related to negative symptoms. Avoidance accounted for significant variation in observer-rated functioning after adjusting for cognitive ability. These results suggest that activation and avoidance may be important therapeutic targets in schizophrenia, with somewhat divergent pathways among psychopathologic features to functional impairment.
doi:10.1097/NMD.0b013e3182349cb7
PMCID: PMC3233969  PMID: 22048138
Schizophrenia; psychosis; activation; avoidance; depression; functioning
19.  Sensitivity and Specificity of the UCSD Performance-based Skills Assessment (UPSA-B) for Identifying Functional Milestones in Schizophrenia 
Schizophrenia research  2011;132(2-3):165-170.
Schizophrenia is a highly debilitating illness that often results in disruption to independent living and employment. However, “gold standard” methods of assessing functional abilities to achieve these milestones are still lacking. In a sample of 367 individuals with schizophrenia, we examined the sensitivity and specificity of the Brief UCSD Performance-based Skills Assessment (UPSA-B) to predict both residential and employment status. Of all individuals residing independently, 75.9% scored 78 or above on the UPSA-B, and of all individuals not residing independently, 59% scored below 78 on the UPSA-B. Of individuals who were employed, 73.9% scored above 82 on the UPSA-B, and of those not employed, 57.8% scored below 82. These results expand upon both the population base and functional milestones with which the UPSA-B is validated, although future work should examine whether the UPSA-B can be used as a decision aid in the likelihood of success in a longitudinal study, such as at critical transitions (post-hospitalization, cessation of supported housing).
doi:10.1016/j.schres.2011.07.022
PMCID: PMC3195873  PMID: 21843926
Psychosis; Functional Capacity; Functioning; Employment; Independence; Well-being
20.  Activity Restriction and Depression in Medical Patients and their Caregivers: A Meta Analysis 
Clinical psychology review  2011;31(6):900-908.
Depression commonly occurs in conjunction with a variety of medical conditions. In addition, family members who care for patients with medical diagnoses often suffer from depression. Therefore, in addition to treating illnesses, physicians and other healthcare professionals are often faced with managing secondary mental health consequences. We conducted a systematic review and meta-analysis of the association between activity restriction and depression in medical patients and their caregivers. A total of 34 studies (N = 8,053) documenting the relationship between activity restriction and depression were identified for the period between January 1980 and June 2010. Effect sizes were calculated as Pearson r correlations using random-effects models. The correlation between activity restriction and depression was positive and of large magnitude (r = 0.39; 95% CI, .34–.44). Activity restriction was most strongly correlated with depression in medical patients (r = 0.45; 95% CI, 0.42–0.48), followed by caregivers (r = 0.34; 95% CI, 0.28–0.41) and community-dwelling adults (r = 0.28; 95% CI, 0.25–0.31). Activity restriction associated with medical conditions is a significant threat to well-being and quality of life, as well as to the lives of their caregivers. Assessment and treatment of activity restriction may be particularly helpful in preventing depression.
doi:10.1016/j.cpr.2011.04.004
PMCID: PMC3148316  PMID: 21600868
Depression; Activity Restriction; Chronic disease; Older adults; Aging; Behavioral Activation; Behavior Therapy
21.  Attitude Toward Own Aging and Mental Health in Post-menopausal Women 
Asian journal of psychiatry  2011;4(1):26-30.
Introduction
Attitudes toward own aging (ATOA) refers to expectations about the personal experience of aging. As of now, there is limited literature that addresses the impact of ATOA on indicators of psychological, physical, and social health. In this study, we examine associations between ATOA and several measures associated with successful aging.
Methods
A detailed cross-sectional survey questionnaire on successful aging was completed by 1,973 older women enrolled in the San Diego site of the Women's Health Initiative study. ATOA was measured using the Philadelphia Geriatric Morale Scale (PGMS)
Results
The final sample consisted of 1151 women. The mean ATOA score was 3.8 indicating generally positive ATOA. Positive ATOA score was significantly associated with younger age, lower income, being married, higher SF-36 Physical Composite scores, higher SF-36 Mental composite scores, lower depression scores, and higher resilience scores. Approximately 40% of variance in ATOA scores was explained by successful aging-related domain scores.
Conclusions
Better physical and emotional functioning, greater resilience and lower depression are associated with more positive ATOA. Associations with sociodemographic traits are complex. Modifying ATOA may have potential to impact a broad range of health and successful aging related outcomes.
doi:10.1016/j.ajp.2011.01.006
PMCID: PMC3098443  PMID: 21607197
Attitude toward aging; Depression; Health; Social status; Spirituality; Personal mastery; Optimism
22.  Integration of the Pleasant Events (PE) and Activity Restriction (AR) Models: Development and Validation of a “PEAR” Model of Negative Outcomes in Alzheimer’s Caregivers 
Behavior therapy  2010;42(1):78-88.
This study examined an activity restriction/pleasurable activities mismatch model for psychosocial and health-related outcomes. A total of 108 spousal caregivers of patients with Alzheimer’s Disease (AD) were assessed for their experience of social and recreational activities over the past month as well as their perception of how restricted they were for engaging in social and recreational activities. Participants were divided into three groups based on their reported activities and activity restriction: HPLR = High Pleasant Events + Low Activity Restriction (i.e., reference group; N = 28); HPHR/LPLR = Either High Pleasant Events + High Activity Restriction or Low Pleasant Events + Low Activity Restriction (N = 43); LPHR = Low Pleasant Events + High Activity Restriction (N = 37). We hypothesized that participants reporting low pleasant events combined with high activity restriction (LPHR) would demonstrate greater disturbance relative to other two groups in multiple outcome domains including: a) greater mood disturbance, b) greater use of negative coping factors, c) reduced use of positive coping strategies, d) reduced report of psychological resource factors (e.g., personal mastery, self-efficacy), and increased report of subjective health difficulties (e.g., sleep disturbance). Results generally supported our hypotheses, suggesting that assessment of both constructs is important for best predicting quality of well-being in AD caregivers, and potentially for establishing maximal effect in behavior therapy for caregivers.
doi:10.1016/j.beth.2009.11.006
PMCID: PMC3163438  PMID: 21292054
Behavioral Activation; Activity Restriction; Alzheimer’s Disease; Well-Being; Coping
23.  Correlates of Spirituality in Older Women 
Aging & mental health  2011;15(1):97-102.
Introduction
The role of spirituality in the context of mental health and successful aging is not well understood. In a sample of community-dwelling older women enrolled at the San Diego site of the Women's Health Initiative study, we examined the association between spirituality and a range of variables associated with successful cognitive and emotional aging, including optimism, resilience, depression, and health-related quality of life (HRQoL).
Methods
A detailed cross-sectional survey questionnaire on successful aging was completed by 1,973 older women. It included multiple self-reported measures of positive psychological functioning (e.g., resilience, optimism,), as well as depression and HRQoL. Spirituality was measured using a 5-item self report scale constructed using two items from the Brief Multidimensional Measure of Religiosity/Spirituality and three items from Hoge's Intrinsic Religious Motivation Scale
Results
Overall, 40% women reported regular attendance in organized religious practice, and 53% reported engaging in private spiritual practices. Several variables were significantly related to spirituality in bivariate associations; however, using model testing, spirituality was significantly associated only with higher resilience, lower income, lower education, and lower likelihood of being in a marital or committed relationship.
Conclusions
Our findings point to a role for spirituality in promoting resilience to stressors, possibly to a greater degree in persons with lower income and education level. Future longitudinal studies are needed to confirm these associations.
doi:10.1080/13607863.2010.501069
PMCID: PMC3017739  PMID: 20924814
Spirituality; religiosity; elderly; successful aging; resilience
24.  Mobile Interventions for Severe Mental Illness: Design and Preliminary Data from Three Approaches 
Mobile devices can be used to deliver psychosocial interventions, yet there is little prior application in severe mental illness. We provide the rationale, design, and preliminary data from three ongoing clinical trials of mobile interventions developed for bipolar disorder or schizophrenia. Project 1 used a personal digital assistant to prompt engagement in personalized self-management behaviors based on real-time data. Project 2 employed experience sampling via text messages to facilitate case management. Project 3 built on group functional skills training for schizophrenia by incorporating between-session mobile phone contacts with therapists. Preliminary findings were of minimal participant attrition, and no broken devices; yet, several operational and technical barriers needed to be addressed. Adherence was similar to that reported in non-psychiatric populations, with high participant satisfaction. Thus, mobile devices appear feasible and acceptable in augmenting psychosocial interventions for severe mental illness, with future research in establishing efficacy, cost-effectiveness, and ethical and safety protocols.
doi:10.1097/NMD.0b013e3181f49ea3
PMCID: PMC3215591  PMID: 20921861
Bipolar disorder; schizophrenia; severe mental illness; psychosocial intervention; ambulatory monitoring; technology; ecological momentary assessment; experience sampling method
25.  Exergames for Subsyndromal Depression in Older Adults: A Pilot Study of a Novel Intervention 
Objectives
Subsyndromal depression (SSD) is several times more common than major depression in older adults, and is associated with significant negative health outcomes. Physical activity can improve depression, yet adherence is often poor. We assessed the feasibility, acceptability, and short-term efficacy and safety of a novel intervention using exergames (entertaining video games that combine game play with exercise) for SSD in older adults.
Methods
Community-dwelling older adults (N = 19, age 63–94) with SSD participated in a 12-week pilot study (with follow-up at 20 to 24 weeks) of Nintendo’s Wii Sports, with three 35-minute sessions a week.
Results
86% of enrolled participants completed the 12-week intervention. There was a significant improvement in depressive symptoms, mental health-related quality of life, and cognitive performance, but not physical health-related quality of life. There were no major adverse events, and improvement in depression was maintained at follow-up.
Conclusions
The findings provide preliminary indication of the benefits of exergames in seniors with SSD. Randomized controlled trials of exergames for late-life SSD are warranted.
doi:10.1097/JGP.0b013e3181c534b5
PMCID: PMC2827817  PMID: 20173423
Physical activity; Aging; Videogames; Depression; Quality of life; Cognition

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