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1.  A Spiritually Based Group Intervention for Combat Veterans With Posttraumatic Stress Disorder 
Purpose
To assess the feasibility, effect sizes, and satisfaction of mantram repetition—the spiritual practice of repeating a sacred word/phrase throughout the day—for managing symptoms of posttraumatic stress disorder (PTSD) in veterans.
Design
A two group (intervention vs. control) by two time (pre- and postintervention) experimental design was used.
Methods
Veterans were randomly assigned to intervention (n = 14) or delayed-treatment control (n = 15). Measures were PTSD symptoms, psychological distress, quality of life, and patient satisfaction. Effect sizes were calculated using Cohen’s d.
Findings
Thirty-three male veterans were enrolled, and 29 (88%) completed the study. Large effect sizes were found for reducing PTSD symptom severity (d = −.72), psychological distress (d = −.73) and increasing quality of life (d = .70).
Conclusions
A spiritual program was found to be feasible for veterans with PTSD. They reported moderate to high satisfaction. Effect sizes show promise for symptom improvement but more research is needed.
doi:10.1177/0898010107311276
PMCID: PMC4083747  PMID: 18356284
posttraumatic stress disorder; veterans; spirituality; quality of life; mindfulness; intervention; meditation; mind–body relaxation
2.  Age at onset and clinical features of late life compulsive hoarding 
Objectives
Compulsive hoarding is a debilitating, chronic disorder, yet we know little about its onset, clinical features, or course throughout the life span. Hoarding symptoms often come to clinical attention when patients are in late life, and case reports of elderly hoarders abound. Yet no prior study has examined whether elderly compulsive hoarders have early or late onset of hoarding symptoms, whether their hoarding symptoms are idiopathic or secondary to other conditions, or whether their symptoms are similar to compulsive hoarding symptoms seen in younger and middle-aged populations. The objectives of this study were to determine the onset and illustrate the course and clinical features of late life compulsive hoarding, including psychiatric and medical comorbitities.
Methods
Participants were 18 older adults (≥60) with clinically significant compulsive hoarding. They were assessed using structured interviews, including the Mini International Neuropsychiatric Interview (MINI), Structured Clinical Interview for DSM-IV (SCID I), Yale–Brown Obsessive Compulsive Scale (YBOCS), and UCLA Hoarding Severity Scale (UHSS). Self-report Measures Included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Sheehan Disability Scale (SDS), and Savings Inventory-Revised (SI-R). Psychosocial and medical histories were also obtained. To determine age at onset, participants were asked to rate their hoarding symptoms and describe major life events that occurred during each decade of their lives.
Results
Results show that (1) onset of compulsive hoarding symptoms was initially reported as being in mid-life but actually found to be in childhood or adolescence. No subjects reported late onset compulsive hoarding. (2) Compulsive hoarding severity increased with each decade of life. (3) Comorbid mood and anxiety disorders were common, but only 16% of patients met criteria for OCD if hoarding symptoms were not counted toward the diagnosis. (4) The vast majority of patients had never received treatment for hoarding. (5) Older adults with compulsive hoarding were usually socially impaired and living alone.
Conclusions
Compulsive hoarding is a progressive and chronic condition that begins early in life. Left untreated, its severity increases with age. Compulsive hoarding should be considered a distinct clinical syndrome, separate from OCD. Unfortunately, compulsive hoarding is largely unrecognized and untreated in older adults.
doi:10.1002/gps.2310
PMCID: PMC4083761  PMID: 19548272
compulsive hoarding; obsessive-compulsive disorder; older adults
3.  Cognitive-behavioral therapy for geriatric compulsive hoarding☆ 
Behaviour research and therapy  2011;49(10):689-694.
This investigation examined response to a manualized cognitive-behavioral therapy (CBT) protocol for compulsive hoarding (Steketee & Frost, 2007) in a sample of 12 adults over age 65. All participants were cognitively intact, not engaging in any other psychotherapy, and had compulsive hoarding as their primary problem. All received 26 sessions of individual CBT over the course of 17 weeks. The primary outcome measures were the Savings Inventory-Revised and UCLA Hoarding Severity Scale, which were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up. Other outcomes included Clinical Global Impression (CGI) scores, depression, anxiety, disability, and clutter image ratings. Results demonstrated statistically significant changes on hoarding severity and depression. However, only three of the twelve participants were classified as treatment responders at post-treatment, and their gains were not maintained at 6-month follow-up. CGI, anxiety, disability, and clutter ratings were unchanged at post-treatment and follow-up. No participants dropped out, but homework compliance was variable and correlated with decreases in hoarding severity. Findings suggest that older adults with compulsive hoarding may require an enhanced or alternative treatment.
doi:10.1016/j.brat.2011.07.002
PMCID: PMC4048717  PMID: 21784412
Hoarding; OCD; Older adults; CBT
4.  Executive functioning in older adults with hoarding disorder 
Background
Hoarding disorder (HD) is a chronic and debilitating psychiatric condition. Midlife HD patients have been found to have neurocognitive impairment, particularly in areas of executive functioning, but the extent to which this is due to comorbid psychiatric disorders has not been clear.
Aims/Method
The purpose of the present investigation was to examine executive functioning in geriatric HD patients without any comorbid Axis I disorders (n = 42) compared with a healthy older adult comparison group (n = 25). We hypothesized that older adults with HD would perform significantly worse on measures of executive functioning (Wisconsin Card Sort Task [Psychological Assessment Resources, Lutz, Florida, USA] (Psychological Assessment Resources, 2003) and the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests [Pearson, San Antonio, TX, USA]).
Results
Older adults with HD showed significant differences from healthy older controls in multiple aspects of executive functioning. Compared with healthy controls, older adults with HD committed significantly more total, non-perseverative errors and conceptual level responses on the Wisconsin Card Sort Task and had significantly worse performance on the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests. Hoarding symptom severity was strongly correlated with executive dysfunction in the HD group.
Conclusions
Compared with demographically-matched controls, older adults with HD have dysfunction in several domains of executive functioning including mental control, working memory, inhibition, and set shifting. Executive dysfunction is strongly correlated with hoarding severity and is not because of comorbid psychiatric disorders in HD patients. These results have broad clinical implications suggesting that executive functioning should be assessed and taken into consideration when developing intervention strategies for older adults with HD.
doi:10.1002/gps.3940
PMCID: PMC4037916  PMID: 23440720
hoarding disorder; executive dysfunction; geriatric; neuropsychology
5.  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
6.  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
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
9.  Comparison of Longer-Term Safety and Effectiveness of Four Atypical Antipsychotics in Patients over Age 40: A Trial Using Equipoise-Stratified Randomization 
Objective
To compare longer-term safety and effectiveness of the four most commonly used atypical antipsychotics (AAPs: aripiprazole, olanzapine, quetiapine, and risperidone) in 332 patients, aged >40 years, having psychosis associated with schizophrenia, mood disorders, PTSD, or dementia, diagnosed using DSM-IV-TR criteria.
Methods
We used Equipoise-Stratified Randomization (a hybrid of Complete Randomization and Clinician’s Choice Methods) that allowed patients or their treating psychiatrists to exclude one or two of the study AAPs, because of past experience or anticipated risk. Patients were followed for up to two years, with assessments at baseline, 6 weeks, 12 weeks, and every 12 weeks thereafter. Medications were administered employing open-label design and flexible dosages, but with blind raters.
Outcome Measures
(1) Primary metabolic markers (body mass index or BMI, blood pressure, fasting blood glucose, LDL cholesterol, HDL cholesterol, and triglycerides), (2) % patients who stay on the randomly assigned AAP for at least 6 months, (3) Psychopathology, (4) % patients who develop Metabolic Syndrome, and (5) % patients who develop serious and non-serious adverse events.
Results
Because of high incidence of serious adverse events, quetiapine was discontinued midway through the trial. There were significant differences among patients willing to be randomized to different AAPs, suggesting that treating clinicians tended to exclude olanzapine and prefer aripiprazole as one of the possible choices in patients with metabolic problems. Yet, the AAP groups did not differ in longitudinal changes in metabolic parameters or on most other outcome measures. Overall results suggested a high discontinuation rate (median duration 26 weeks prior to discontinuation), lack of significant improvement in psychopathology, and high cumulative incidence of metabolic syndrome (36.5% in one year) and of serious (23.7%) and non-serious (50.8%) adverse events for all AAPs in the study.
Conclusions
Employing a study design that closely mimicked clinical practice, we found a lack of effectiveness and a high incidence of side effects with four commonly prescribed AAPs across diagnostic groups in patients over age 40, with relatively few differences among the drugs. Caution in the use of these drugs is warranted in middle-aged and older patients.
doi:10.4088/JCP.12m08001
PMCID: PMC3600635  PMID: 23218100
Antipsychotic; Metabolic Syndrome; Schizophrenia; Dementia; Mood disorder; Equipoise-Stratified Randomization
10.  Adding antidepressants to antipsychotics for treatment of subsyndromal depressive symptoms in schizophrenia: Impact on positive and negative symptoms 
Indian Journal of Psychiatry  2013;55(2):144-148.
Objectives:
It remains unclear how augmenting anti-psychotic medications with anti-depressants impacts primary positive and negative symptoms of schizophrenia. In this study, we used data collected from a randomized trial comparing citalopram to placebo for management of subsyndromal depression (SSD) in schizophrenia and schizoaffective disorder, to assess the effects of antidepressant augmentation on positive and negative symptoms.
Materials and Methods:
Participants in this study conducted at the University of California, San Diego and the University of Cincinnati, were persons with schizophrenia or schizoaffective disorder aged 40 or older and who met study criteria for SSD. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current anti-psychotic medication. Analysis of covariance was used to compare changes in positive and negative syndrome scale (PANSS) scores between treatment groups. We also assessed mediating effects of improvement in depression and moderating effects of multiple factors on positive and negative symptoms.
Results:
There was significant improvement in PANSS negative symptoms scores in the citalopram group, which was partially mediated by improvement in depressive symptoms. There was no effect on PANSS positive scores.
Conclusions:
In patients with schizophrenia/schizoaffective disorder, treating depressive symptoms with citalopram appears to carry the added benefit of improving negative symptoms.
doi:10.4103/0019-5545.111452
PMCID: PMC3696237  PMID: 23825848
Citalopram; depression; negative symptom; schizophrenia
11.  Does Antidepressant Treatment Improve Cognition in Older People with Schizophrenia or Schizoaffective Disorder and Comorbid Subsyndromal Depression? 
Neuropsychobiology  2012;65(3):168-172.
Background
Subsyndromal symptoms of depression (SSD) in patients with schizophrenia are common and clinically important. While treatment of depression in major depressive disorder may partially ameliorate cognitive deficits, the cognitive effects of antidepressant medications in patients with schizophrenia or schizoaffective disorder and SSD are unknown.
Methods
The goal of this study was to assess the impact of SSD and their treatment on cognition in participants with schizophrenia or schizoaffective disorder aged ≥40 years. Participants were randomly assigned to a flexible dose treatment with citalopram or placebo augmentation of their current medication for 12 weeks. An ANCOVA compared improvement in the cognitive composite scores, and a linear model determined the moderation of cognition on treatment effects based on the Hamilton Depression Rating Scale and the Calgary Depression Rating Scale scores between treatment groups.
Results
There were no differences between the citalopram and placebo groups in changes in cognition. Baseline cognitive status did not moderate antidepressant treatment response.
Conclusions
Although there are other cogent reasons why SSD in schizophrenia warrant direct intervention, treatment does not substantially affect the level of cognitive functioning. Given the effects of cognitive deficits associated with schizophrenia on functional disability, there remains an ongoing need to identify effective means of directly ameliorating them.
doi:10.1159/000331141
PMCID: PMC3701889  PMID: 22456094
Schizophrenia; Citalopram; Cognition; Subsyndromal depression
12.  Older Patients With Schizophrenia: Does Military Veteran Status Matter? 
Objective
The objective of this study was to examine the influence of military veteran status within a data set of older patients with schizophrenia or schizoaffective disorder.
Methods
The data set was examined to determine whether veteran status influenced psychopathology, quality of life, cognitive performance, and everyday functioning among 746 male participants.
Results
There were no significant differences between the groups on measures of premorbid functioning or psychopathology. Veterans in the sample were older, had a higher likelihood of being married (or previously married), had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. Though veterans reported worse physical health, they also had better everyday functioning and better performance on some cognitive tasks than nonveterans. Fewer veterans endorsed current use of substances than nonveterans.
Conclusions
There were several differences based on veteran status, including everyday functioning, health-related quality of life, cognitive performance, and current substance use.
doi:10.1097/JGP.0b013e3182096ae5
PMCID: PMC3286234  PMID: 22354115
aging; cognitive functioning; quality of life; schizophrenia; substance use; veterans
13.  The Relationship Between Outdoor Activity and Health in Older Adults Using GPS 
Physical activity (PA) provides health benefits in older adults. Research suggests that exposure to nature and time spent outdoors may also have effects on health. Older adults are the least active segment of our population, and are likely to spend less time outdoors than other age groups. The relationship between time spent in PA, outdoor time, and various health outcomes was assessed for 117 older adults living in retirement communities. Participants wore an accelerometer and GPS device for 7 days. They also completed assessments of physical, cognitive, and emotional functioning. Analyses of variance were employed with a main and interaction effect tested for ±30 min PA and outdoor time. Significant differences were found for those who spent >30 min in PA or outdoors for depressive symptoms, fear of falling, and self-reported functioning. Time to complete a 400 m walk was significantly different by PA time only. QoL and cognitive functioning scores were not significantly different. The interactions were also not significant. This study is one of the first to demonstrate the feasibility of using accelerometer and GPS data concurrently to assess PA location in older adults. Future analyses will shed light on potential causal relationships and could inform guidelines for outdoor activity.
doi:10.3390/ijerph9124615
PMCID: PMC3546779  PMID: 23330225
physical activity; older adults; outdoor time; accelerometry; Global Positioning System (GPS); physical functioning; cognitive functioning; health
14.  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
15.  Functioning in Middle Aged and Older Patients With Schizophrenia and Depressive Symptoms: Relationship to Psychopathology 
Background
Depressive symptoms are common in middle aged and older patients with schizophrenia, The authors hypothesized that worse functioning in these patients would be associated with worse psychopathology.
Methods
Outpatients with schizophrenia were ≥40 years old with subsyndromal depression and Hamilton Depression Rating Scale Scores of ≥8. Exclusions were dementia, two months of either mania or major depression or 1 month active substance abuse/dependence. The authors administered performance based functional assessments, the Positive and Negative Syndrome Scale of Schizophrenia [PANSS], and Calgary Depression Rating Scale.
Results
PANSS (−) scores were negatively correlated with the UCSD Performance Skills Based Assessment, Social Skills Performance Assessment and Medication Management Ability Assessment total error (MMAA) scores. Digit symbol scores served as a moderator of the relationship between MMAA and PANSS (−) scores.
Conclusions
Negative symptoms were associated with functioning. The relationship between negative symptoms and medication etrors seem to weaken in subjects with quicker processing speed.
doi:10.1097/JGP.0b013e31816ff746
PMCID: PMC3110689  PMID: 18669944
Schizophrenia; functioning; psychopathology; negative symptoms
16.  Treatment of Subsyndromal Depressive Symptoms in Middle-Age and Older Patients With Schizophrenia: Effect of Age on Response 
Objective
The authors hypothesized that age would moderate the response of patients with schizophrenia and subsyndromal depression (SSD) treated citalopram with depressive symptoms and other outcomes. Also, older patients would exhibit more side effects with citalopram.
Methods
Participants of 40 years or older had schizophrenia or schizoaffective disorder with SSD. Patients randomly received flexible dosing of citalopram or placebo augmentation of their antipsychotic medication. Linear regression determined whether age had any moderating effect on depressive symptoms, global psychopathology, negative symptoms, mental functioning, and quality of life. Age-related side effects were examined.
Results
There were no significant drug group by age interaction in depressive or psychotic symptoms, mental Short Form-12, or quality of life scores. Similarly, there were few age-related side effect differences.
Conclusion
Symptoms in younger and older patients with schizophrenia and SSD treated with citalopram seem to respond similarly. Adverse events do not seem to differ with age.
doi:10.1097/JGP.0b013e3181dba12f
PMCID: PMC3079763  PMID: 20808103
Schizophrenia; age differences; citalopram; depression; psychopathology; quality of life
17.  Treatment of subsyndromal depressive symptoms in middle-aged and older adults with schizophrenia: effect on functioning 
Background
Subsyndromal symptoms of depression (SSD) in patients with schizophrenia are common and clinically important. SSRI’s appear to be helpful in alleviating depressive symptoms in patients with schizophrenia who have SSD in patients age 40 and greater. It is not known whether SSRI’s help improve functioning in this population. We hypothesized that treating this population with the SSRI citalopram would lead to improvements in social, mental and physical functioning as well as improvements in medication management and quality of life.
Methods
Participants were 198 adults ≥ 40 years old with schizophrenia or schizoaffective disorder who met study criteria for subsyndromal depression based on having two or more of the nine DSM-IV symptoms of a major depressive episode, for at least 2 weeks, and a Hamilton depression rating scale (HAM-D 17) score ≥ 8. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current antipsychotic medication(s) which was stable for 1 month. Subjects were assessed with the following functional scales at baseline and at the end of the 12-week trial: (1) social skills performance assessment (SSPA), (2) medication management ability assessment (MMAA), (3) mental and physical components of the medical outcomes study SF-12 Scale, and (4) the Heinrichs quality of life scale (QOLS). Analysis of covariance (ANCOVA) was used to compare differences between endpoint scores of the citalopram and placebo treated groups, controlling for site and baseline scores. ANCOVAs were also used to compare differences in the above endpoint scores in responders versus non-responders (responders = those with > 50% reduction in depressive symptoms).
Results
Overall, the citalopram group had significantly higher SSPA, mental functioning SF-12, and quality of life scale (QOLS) scores compared to the placebo group. There was no effect on MMAA or physical functioning SF-12 scores. Responders had significantly better endpoint mental SF-12 and QOLS scores compared to non-responders. Response to citalopram in terms of depressive symptoms mediated the effect of citalopram on mental functioning, but not on the quality of life.
Conclusions
Citalopram augmentation of antipsychotic treatment in middle aged and older patients with schizophrenia and subsyndromal depression appears to improve social and mental health functioning as well as quality of life. Thus it is important for clinicians to monitor these aspects of functioning when treating this population of patients with schizophrenia with SSRI agents.
doi:10.1002/gps.2318
PMCID: PMC3073368  PMID: 19711335
schizophrenia; citalopram; depression; functioning; social skills
18.  Course of Neurocognitive Deficits in the Prodrome and First Episode of Schizophrenia 
Neuropsychology  2010;24(1):109-120.
Understanding the trajectory of cognitive changes in the development of schizophrenia may shed light on the neurodevelopmental processes in the beginning stage of illness. Subjects at risk for psychosis (AR, n=48), patients in their first episode of schizophrenia (FE, n=20) and normal comparison subjects (NC, n=29) were assessed on a neurocognitive battery at baseline and at a 6-month follow-up. There were significant group differences across all cognitive domains as well as a significant group by time interaction in the verbal learning domain. After statistically controlling for practice effects and regression to the mean, a high proportion of FE subjects showed an improvement in verbal learning, while a significant number of AR subjects improved in general intelligence. Moreover, a higher than expected percentage of FE subjects, as well as AR subjects who later converted to psychosis, showed a deterioration in working memory and processing speed. These inconsistent trajectories suggest that some domains may improve with stabilization in the early stages of psychosis, while others may decline with progression of the illness, indicating possible targets for cognitive remediation strategies and candidate vulnerability markers for future psychosis.
doi:10.1037/a0016791
PMCID: PMC2808194  PMID: 20063952
NEUROPSYCHOLOGICAL; LONGITUDINAL; SCHIZOPHRENIA; AT RISK; PRODROMAL
19.  Multimedia Consent for Research in People With Schizophrenia and Normal Subjects: a Randomized Controlled Trial 
Schizophrenia Bulletin  2008;35(4):719-729.
Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.
doi:10.1093/schbul/sbm148
PMCID: PMC2696362  PMID: 18245061
bioethics; mental competency; informed consent; multimedia learning; cognition disorders; schizophrenia
20.  Measurement and Predictors of Resilience Among Community-Dwelling Older Women 
Journal of psychiatric research  2008;43(2):148-154.
Background
Resilience, the ability to adapt positively to adversity, may be an important factor in successful aging. However, the assessment and correlates of resilience in elderly individuals have not received adequate attention.
Method
A total of 1,395 community-dwelling women over age 60 who were participants at the San Diego Clinical Center of the Women’s Health Initiative completed the Connor-Davidson Resilience Scale (CD-RISC), along with other scales pertinent to successful cognitive aging. Internal consistency and predictors of the CD-RISC were examined, as well as the consistency of its factor structure with published reports.
Results
The mean age of the cohort was 73 (7.2) years and 14% were Hispanic, 76% were non-Hispanic white, and nearly all had completed a high school education (98%). The mean total score on the CD-RISC was 75.7 (SD=13.0). This scale showed high internal consistency (Cronbach’s alpha=0.92). Exploratory factor analysis yielded four factors (somewhat different from those previously reported among younger adults) that reflected items involving: 1) personal control and goal orientation, 2) adaptation and tolerance for negative affect, 3) leadership and trust in instincts, and 4) spiritual coping. The strongest predictors of CD-RISC scores in this study were higher emotional well-being, optimism, self-rated successful aging, social engagement, and fewer cognitive complaints.
Conclusions
Our study suggests that the CD-RISC is an internally consistent scale for assessing resilience among older women, and that greater resilience as assessed by the CD-RISC related positively to key components of successful aging.
doi:10.1016/j.jpsychires.2008.03.007
PMCID: PMC2613196  PMID: 18455190
Resilience; adaptation; elderly; successful aging; cognition; optimism
21.  ANTIDEPRESSANT RESPONSE TO PARTIAL SLEEP DEPRIVATION IN UNIPOLAR DEPRESSION IS NOT RELATED TO STATE ANXIETY 
Depression and anxiety  2008;25(7):E12-E14.
One night of total or partial sleep deprivation (SD) produces a temporary remission in up to 60% of patients with major depression, yet mechanisms remain unclear. We investigated whether the antidepressant effects of SD are caused, even partially, by an improvement in anxiety. As part of a functional magnetic resonance imaging study, 19 unmedicated major depression patients and eight controls completed the Spielberger State/Trait Anxiety Inventory (STAI) (state version) at baseline and sleep-deprived scanning sessions. We found (1) greater anxiety in patients than controls; (2) no baseline or SD STAI difference between responders and nonresponders; (3) no STAI change with SD in any subject group; and (4) no significant correlation between any STAI and Hamilton Depression Rating Scale measures. Our findings did not provide support for an anxiolytic process associated with the antidepressant effects of SD.
doi:10.1002/da.20424
PMCID: PMC2564796  PMID: 17960641
depressive disorder; major; psychiatric somatic therapies; Spielberger State/Trait Anxiety Inventory; psychiatric status rating scales; anxiety disorders
22.  Polysomnography and criteria for the antidepressant response to sleep deprivation 
Journal of affective disorders  2007;101(1-3):195-200.
Background
One night of total or partial sleep deprivation (SD) produces a temporary remission in 40–60% of patients with major depression. Yet no attempts to determine the optimum response criterion(a) for the antidepressant response to SD have been published.
Methods
Twenty-three unmedicated major depression patients received polysomnography (PSG) on an adaptation night; a baseline night; a partial SD (PSD) night (awake after 3 a.m.); and a “recovery” night. Subjects received the Hamilton Depression Rating Scale (HDRS17) at standard times during baseline and PSD days and at 8 a.m. after the “recovery” night. Response was defined as percent decrease in the modified HDRS17 (HDRS17Mod) (omitting sleep and weight loss items) from baseline to the minimum following PSD. Using cutoffs of 30%, 35%, 40%, and 50% to dichotomize responders and nonresponders, PSG variables were analyzed for between-group differences.
Results
All cutoffs differentiated responders’ and nonresponders’ mood response to PSD despite similar baseline values. Sleep continuity measures most consistently differed between responders and nonresponders on baseline and recovery nights. None of the response cutoffs tested were clearly “best” in terms of detecting the most PSG differences between groups.
Limitations
More subjects may be needed.
Conclusions
Given the increasing interest in SD for clinical and research applications, as well as its proposed use for subtyping depression, further study to determine the optimal response criterion(a) for the antidepressant response to SD is warranted. Planned pooling of multisite data on standardized SD protocols could help determine the optimal cutpoint for response.
doi:10.1016/j.jad.2006.11.020
PMCID: PMC2366891  PMID: 17250898
Depressive disorder; Major; Hamilton depression rating scale; Sleep deprivation; Polysomnography

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