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1.  Improving the Understanding of the Link between Cognition and Functional Capacity in Schizophrenia and Bipolar Disorder 
Schizophrenia research  2015;169(0):121-127.
OBJECTIVE
Deficits in cognitive functioning are related to functional disability in people with serious mental illness. Measures of functional capacity are commonly used as a proxy for functional disabilities for cognitive remediation programs, and robust linear relationships between functional capacity and cognitive deficits are frequently observed. This study aimed to determine whether a curvilinear relationship better approximates the association between cognitive functioning and functional capacity.
METHOD
Two independent samples were studied. Study 1: Participants with schizophrenia (n=435) and bipolar disorder (n=390) aged 18–83 completed a neuropsychological battery and a performance-based measure of functional capacity. Study 2: 205 participants with schizophrenia (age range=39–72) completed a brief neuropsychological screening battery and a performance-based measure of functional capacity. For both studies, linear and quadratic curve estimations were conducted with cognitive performance predicting functional capacity scores.
RESULTS
Significant linear and quadratic trends were observed for both studies. Study 1: In both the schizophrenia and bipolar participants, when cognitive composite z-scores were >0 (indicating normal to above normal performance), cognition was not related to functional capacity. Study 2: When neuropsychological screening battery z-scores were >−1 (indicating low average to average performance), cognition was not related to functional capacity.
CONCLUSIONS
These results illustrate that in cognitively normal adults with serious mental illness, the relationship between cognitive function and functional capacity is relatively weak. These findings may aid clinicians and researchers determine who may optimally benefit from cognitive remediation programs, with greater benefits possibly being achieved for individuals with cognitive deficits relative to individuals with normal cognition.
doi:10.1016/j.schres.2015.09.017
PMCID: PMC4681671  PMID: 26427917
2.  Is Post-Traumatic Stress Disorder Associated with Premature Senescence? A Review of the Literature 
Post-Traumatic Stress Disorder (PTSD) has major public health significance. Evidence that PTSD may be associated with premature senescence (early or accelerated aging) would have major implications for quality of life and healthcare policy. We conducted a comprehensive review of published empirical studies relevant to early aging in PTSD. Our search included the PubMed, PsycINFO and PILOTS databases for empirical reports published since the year 2000 relevant to early senescence and PTSD, including: (1) biomarkers of senescence (leukocyte telomere length (LTL) and pro-inflammatory markers), (2) prevalence of senescence-associated medical conditions, and (3) mortality rates. All six studies examining LTL indicated reduced LTL in PTSD (pooled Cohen’s d = 0.76). We also found consistent evidence of increased pro-inflammatory markers in PTSD (mean Cohen’s ds), including C-reactive protein = 0.18, Interleukin-1 beta = 0.44, Interleukin-6 = 0.78, and tumor necrosis factor alpha = 0.81. The majority of reviewed studies also indicated increased medical comorbidity among several targeted conditions known to be associated with normal aging, including cardiovascular disease, type 2 diabetes mellitus, gastrointestinal ulcer disease, and dementia. We also found seven of 10 studies indicated PTSD to be associated with earlier mortality (average HR = 1.29). In short, evidence from multiple lines of investigation suggests that PTSD may be associated with a phenotype of accelerated senescence. Further research is critical to understand the nature of this association. There may be a need to re-conceptualize PTSD beyond the boundaries of mental illness, and instead as a full systemic disorder.
doi:10.1016/j.jagp.2015.04.001
PMCID: PMC4568841  PMID: 25959921
3.  Depression as a predictor of adherence to adjuvant endocrine therapy (AET) in women with breast cancer: a systematic review and meta-analysis 
The purpose of this meta-analysis was to analyze the available evidence concerning the effects of depression on non-adherence to adjuvant endocrine therapy (AET) in women with breast cancer. MEDLINE and PsycInfo databases from inception through May 1, 2015 were searched using terms related to AET adherence. Articles were reviewed and selected based on predetermined selection criteria, and effect sizes from included studies were extracted. Pooled effect estimates were obtained using random-effects meta-analyses. Of the 312 articles identified, 9 met the inclusion criteria. Overall, depression was significantly associated with non-adherence to AET (Cohen’s d = 0.35, 95 % CI 0.19–0.52). This effect was not significantly moderated by patient age (<65 vs ≥65 years), length of study follow-up (<18 months vs ≥18 months), or method of assessing adherence (objective vs self-report). However, within these subgroups, significant effects of depression were found only for younger patients (d = 0.46; 95 % CI 0.19–0.72) and in studies of shorter duration (<18 months) (d = 0.49; 95 % CI 0.22–0.76). These results suggest that AET adherence may be lower among women with greater depressive symptoms, and this effect may be exacerbated in younger women during the early phases (<18 months) of AET. Management of depressive symptoms in women with breast cancer may help in enhancing adherence to AET and improve cancer treatment outcomes.
doi:10.1007/s10549-015-3471-7
PMCID: PMC4861253  PMID: 26077640
Mood; Tamoxifen; Aromatase inhibitor; Mental illness; Estrogen therapy; Outcomes
4.  The temporal course and clinical correlates of subjective impulsivity in bipolar disorder as revealed through ecological momentary assessment 
Journal of affective disorders  2015;193:145-150.
Background
Impulsivity is frequently linked with bipolar disorder and is associated with mania and negative outcomes. The temporal dynamics of subjective impulsivity are unclear, in particular whether impulsivity precedes or follows changes in positive or negative affect.
Methods
A total of 41 outpatients with bipolar disorder (I or II) were provided with mobile devices for 11 weeks and completed twice-daily surveys about affective states and subjective impulsivity. We examined the association between aggregate subjective impulsivity with baseline global cognitive function, suicide risk ratings, and medication adherence, as well as concurrent and lagged associations with momentary positive and negative affect ratings.
Results
A total of 2902 ratings were available across study subjects. Higher aggregate mean ratings of impulsivity were associated with worse baseline global cognitive function, prior suicide attempts, and self-reported problems with medication adherence, as well as more severe manic (but not depressive) symptoms. Time-lagged models indicated that greater negative affect, but not positive affect, predicted subsequent increases in subjective impulsivity, which, in turn, predicted diminished positive affect.
Limitations
Other measures of impulsivity with which to validate subjective ratings were unavailable and the sample was restricted to generally clinically stable outpatients.
Conclusions
Subjective impulsivity as measured by daily monitoring was associated with worse cognitive function and self-rated medication adherence, and higher suicide risk ratings. Impulsivity may be a maladaptive strategy to regulate negative affect in bipolar disorder.
doi:10.1016/j.jad.2015.12.016
PMCID: PMC4915941  PMID: 26773907
Assessment; Mobile health; Emotion; Bipolar disorder; Technology; Time series analysis
5.  Complex interplay between health and successful aging: Role of perceived stress, resilience, and social support 
Psychological and psychosocial resources, including resilience and social support, have traditionally been studied in the context of the stress paradigm and, more recently, in the context of successful aging. This study used moderated mediation analyses to examine the role of perceived stress in the relationships between physical and mental health functioning and self-rated successful aging (SRSA), and whether differences between people in level of resilience and social support changes the role of perceived stress in these relationships. A cross-sectional study of 1,006 older adults (Mean=77 years) completed scales addressing SRSA, physical and mental health functioning, perceived stress, resilience, and social support. Results indicated that the strength of relationships between both physical and mental health functioning and SRSA were reduced after accounting for variation in level of perceived stress. The role of perceived stress in the association between mental health functioning and SRSA was found to be stronger among participants with the highest levels of resilience, and the influence of perceived stress on the degree of relationship between physical health functioning and SRSA was stronger among those with greatest social support. These findings suggest that interventions to reduce perceived stress may help break the link between disability and poor well-being in older adults. The findings further suggest that the impact of such interventions might differ depending on psychological resources (i.e., resilience) for mental health disabilities and external resources (i.e., social support) for those with physical health problems. The complex interplay of these factors should be taken into account in clinical settings.
doi:10.1016/j.jagp.2014.08.004
PMCID: PMC4329284  PMID: 25217186
Aging; Perceived Stress; Resilience; Disability; Emotional Health; Psychosocial Functioning
6.  Current Smoking is Associated with Worse Cognitive and Adaptive Functioning in Serious Mental Illness 
Acta psychiatrica Scandinavica  2015;131(5):333-341.
Objective
Cigarette smoking is highly prevalent among people with bipolar disorder or schizophrenia. Few studies have examined whether smoking history is associated with adaptive functioning among individuals diagnosed with these serious mental illnesses.
Method
In a large relatively homogenous cohort of patients with either bipolar disorder (n=363) or schizophrenia (n=400), we investigated the association between cigarette smoking status, intensity, and cumulative exposure and performance on a comprehensive battery of neurocognitive, functional capacity, informant-rated functional measures. The associations were adjusted for variation in sociodemographic indicators, psychopathologic symptoms, and substance use.
Results
There was an average of 12 pack years of smoking across the sample. People with schizophrenia reported double the rate of current smoking compared to patients with bipolar disorder. Adjusting for demographic covariates, current smokers had worse composite cognitive functioning and poorer functional outcome than past or never smokers. There were no significant differences between never and past smokers, and these effects were evident in both bipolar disorder and schizophrenia.
Conclusion
Current smokers with either schizophrenia or bipolar disorder evidence worse cognitive and adaptive functioning functional outcome, even when demographic covariates are considered.
Significant Outcomes
Patients with schizophrenia had double the rate of smoking compared to patients with bipolar disorder
Current smoking was negatively associated with cognitive functioning, functional capacity, and informant reported functional outcomes in both patients with schizophrenia and bipolar disorder, after adjusting for sociodemographic covariates
Limitations
The study was cross-sectional and so causal associations cannot be inferred
Tobacco use was assessed with a self-report instrument
The sample was relatively homogenous and high function and may not generalize to ethnically diverse or more symptomatic samples
doi:10.1111/acps.12380
PMCID: PMC4400207  PMID: 25559296
Cognition; Neuropsychology; Schizophrenia; Psychosis; Bipolar Disorder; Nicotine
8.  Augmenting Psychoeducation with a Mobile Intervention for Bipolar Disorder: A Randomized Controlled Trial 
Background
Psychosocial interventions for bipolar disorder are frequently unavailable and resource intensive. Mobile technology may improve access to evidence-based interventions and may increase their efficacy. We evaluated the feasibility, acceptability and efficacy of an augmentative mobile ecological momentary intervention targeting self-management of mood symptoms.
Methods
This was a randomized single-blind controlled trial with 82 consumers diagnosed with bipolar disorder who completed a four-session psychoeducational intervention and were assigned to 10 weeks of either: 1) mobile device delivered interactive intervention linking patient-reported mood states with personalized self-management strategies, or 2) paper-and-pencil mood monitoring. Participants were assessed at baseline, 6 weeks (mid-point), 12 weeks (post-treatment), and 24 weeks (follow up) with clinician-rated depression and mania scales and self-reported functioning.
Results
Retention at 12 weeks was 93% and both conditions were associated with high satisfaction. Compared to the paper-and-pencil condition, participants in the augmented mobile intervention condition showed significantly greater reductions in depressive symptoms at 6 and 12 weeks (Cohen's d for both were d=0.48). However, these effects were not maintained at 24-week follow up. Conditions did not differ significantly in the impact on manic symptoms or functional impairment.
Limitations
This was not a definitive trial and was not powered to detect moderators and mediators.
Conclusions
Automated mobile-phone intervention is feasible, acceptable, and may enhance the impact of brief psychoeducation on depressive symptoms in bipolar disorder. However, sustainment of gains from symptom self-management mobile interventions, once stopped, may be limited.
doi:10.1016/j.jad.2014.10.053
PMCID: PMC4339469  PMID: 25479050
Bipolar disorder; psychotherapy; technology; internet-based treatments; depression; ecological momentary assessment
9.  Neurocognitive and Functional Correlates of Mobile Phone Use in Middle-Aged and Older Patients with Schizophrenia 
Aging & mental health  2015;20(1):29-35.
Objectives
Our objective was to examine the association of mobile phone use and ownership with psychopathology, cognitive functioning and functional outcome in 196 outpatients aged 40 and older who were diagnosed with schizophrenia.
Methods
Participants reported their past and current mobile phone use on a standardized self-report scale and they were administered tests of global cognition, functional capacity and informant-rated functional outcome.
Results
The great majority of subjects had used a mobile phone (78%) but few currently owned one (27%). After adjusting for age (mean age 51), any past mobile phone use was associated with less severe negative symptoms, and higher global cognitive performance, functional capacity, and functional outcome. A total of 60% of participants reported being comfortable with mobile phones, but comfort was not associated with any cognitive or functional outcomes.
Conclusions
Most older patients with schizophrenia have used mobile phones and lifetime mobile phone use is a positive indicator of cognitive and functional status.
doi:10.1080/13607863.2015.1008987
PMCID: PMC4568167  PMID: 25768842
Psychosis; cognitive functioning; disability; technology; aging
10.  Why Does Placement of Persons with Alzheimer's Disease into Long-term Care Improve Caregivers’ Well-Being? Examination of Psychological Mediators 
Psychology and aging  2014;29(4):776-786.
Caregiving for individuals with Alzheimer's Disease (AD) is associated with chronic stress and elevated symptoms of depression. Placement of the care receiver (CR) into a long-term care setting may be associated with improved caregiver well-being; however, the psychological mechanisms underlying this relationship are unclear. This study evaluated whether decreases in activity restriction and increases in personal mastery mediated placement-related reductions in caregiver depressive symptoms. In a five-year longitudinal study of 126 spousal AD caregivers, we used multilevels models to evaluate placement-related changes in depressive symptoms (CESD-10), activity restriction (Activity Restriction Scale), and personal mastery (Pearlin Mastery Scale) in 44 caregivers who placed their spouses into long-term care relative to caregivers who never placed their CRs. The Monte Carlo Method for Assessing Mediation (MCMAM) was used to evaluate the significance of the indirect effect of activity restriction and personal mastery on post-placement changes in depressive symptoms. Placement of the CR was associated with significant reductions in depressive symptoms and activity restriction, while also being associated with increased personal mastery. Lower activity restriction and higher personal mastery were associated with reduced depressive symptoms. Furthermore, both variables significantly mediated the effect of placement on depressive symptoms. Placement-related reductions in activity restriction and increases in personal mastery are important psychological factors that help explain post-placement reductions in depressive symptoms. The implications for clinical care provided to caregivers are discussed.
doi:10.1037/a0037626
PMCID: PMC4267921  PMID: 25133414
stress; depression; activity restriction; personal mastery; Alzheimer's Disease
11.  Positive Affect and Sleep in Spousal Alzheimer Caregivers: A Longitudinal Study 
Behavioral sleep medicine  2013;12(5):358-372.
We examined the longitudinal relationship between positive affect (PA) and sleep in 126 spousal Alzheimer’s disease caregivers. Caregivers underwent four yearly assessments for the Positive and Negative Affect Schedule, the self-rated Pittsburgh Sleep Quality Index, and actigraphy to objectify nighttime total sleep time, wake after sleep onset and percent sleep. Increased levels of PA and a greater positivity (i.e., positive-to-negative affect) ratio were significantly associated with better subjective sleep over the entire study period. Yearly increases in PA -even when controlling for negative affect (NA)- and in the positivity ratio also were associated with better subjective sleep. PA and actigraphy measures showed no significant relationship. Increased PA is longitudinally associated with better sleep in dementia caregivers largely independent of NA.
doi:10.1080/15402002.2013.819470
PMCID: PMC3999303  PMID: 24156281
12.  The effect of language on functional capacity assessment in middle-aged and older US Latinos with schizophrenia 
Psychiatry research  2014;218(0):31-34.
The U.S. Latino population is steadily increasing, prompting a need for cross-cultural outcome measures in schizophrenia research. This study examined the contribution of language to functional assessment in middle-aged Latino patients with schizophrenia by comparing 29 monolingual Spanish-speakers, 29 Latino English-speakers, and 29 non-Latino English-speakers who were matched on relevant demographic variables and who completed cognitive and functional assessments in their native language. There were no statistically significant differences between groups on the four everyday functioning variables (UCSD Performance-Based Skills Assessment [UPSA], Social Skills Performance Assessment [SSPA], Medication Management Ability Assessment [MMAA], and the Global Assessment of Functioning [GAF]). The results support the cross-linguistic and cross-cultural acceptability of these functional assessment instruments. It appears that demographic variables other than language (e.g., age, education) better explain differences in functional assessment among ethnically diverse subpopulations. Considering the influence of these other factors in addition to language on functional assessments will help ensure that measures can be appropriately interpreted among the diverse residents of the United States.
doi:10.1016/j.psychres.2014.04.011
PMCID: PMC4060983  PMID: 24751379
everyday functioning; psychosis; geriatric
13.  Association of obesity and treated hypertension and diabetes with cognitive ability in bipolar disorder and schizophrenia 
Bipolar disorders  2014;16(4):422-431.
Objectives
People with bipolar disorder or schizophrenia are at greater risk for obesity and other cardio-metabolic risks, and several prior studies have linked these risks to poorer cognitive ability. In a large ethnically homogenous outpatient sample, we examined associations among variables related to obesity, treated hypertension and/or diabetes, and cognitive abilities in these two patient populations.
Methods
In a study cohort of outpatients with either bipolar disorder (n = 341) or schizophrenia (n = 417), we investigated the association of self-reported body mass index and current use of medications for hypertension or diabetes with performance on a comprehensive neurocognitive battery. We examined sociodemographic and clinical factors as potential covariates.
Results
Patients with bipolar disorder were less likely to be overweight or obese than patients with schizophrenia, and also less likely to be prescribed medication for hypertension or diabetes. However, obesity and treated hypertension were associated with worse global cognitive ability in bipolar disorder (as well as with poorer performance on individual tests of processing speed, reasoning/problem-solving, and sustained attention), with no such relationships observed in schizophrenia. Obesity was not associated with symptom severity in either group.
Conclusions
Although less prevalent in bipolar disorder compared to schizophrenia, obesity was associated with substantially worse cognitive performance in bipolar disorder. This association was independent of symptom severity and not present in schizophrenia. Better understanding of the mechanisms and management of obesity may aid in efforts to preserve cognitive health in bipolar disorder.
doi:10.1111/bdi.12200
PMCID: PMC4047181  PMID: 24725166
bipolar disorder; diabetes; health risk factors; hypertension; neuropsychology; obesity; psychosis
14.  Longitudinal Relationship of Low Leisure Satisfaction but not Depressive Symptoms With Systemic Low-Grade Inflammation in Dementia Caregivers 
Objectives.
This study aimed to further elucidate the biobehavioral mechanisms linking dementia caregiving with an increased cardiovascular disease risk. We hypothesized that both elevated depressive symptoms and a behavioral correlate of depression, low leisure satisfaction, are associated with systemic inflammation.
Method.
We studied 121 elderly Alzheimer’s disease caregivers who underwent 4 annual assessments for depressive symptoms, leisure satisfaction, and circulating levels of inflammatory markers. We used mixed-regression analyses controlling for sociodemographic and health-relevant covariates to examine longitudinal relationships between constructs of interest.
Results.
There were inverse relationships between total leisure satisfaction and tumor necrosis factor-α (TNF-α; p = .047), interleukin-8 (IL-8; p < .001), and interferon-γ (IFG; p = .020) but not with IL-6 (p = .21) and C-reactive protein (p = .65). Lower enjoyment from leisure activities was related to higher levels of TNF-α (p = .045), IL-8 (p < .001), and IFG (p = .002), whereas lower frequency of leisure activities was related only to higher IL-8 levels (p = .023). Depressive symptoms were not associated with any inflammatory marker (all p values > .17). Depressive symptoms did not mediate the relationship between leisure satisfaction and inflammation.
Discussion.
Lower satisfaction with leisure activities is related to higher low-grade systemic inflammation. This knowledge may provide a promising way of improving cardiovascular health in dementia caregivers through behavioral activation treatments targeting low leisure satisfaction.
doi:10.1093/geronb/gbt020
PMCID: PMC3983912  PMID: 23650246
Biomarkers; Blood coagulation; Cardiovascular disease; Depression; Inflammation; Psychological stress.
15.  Reduced Activity Restriction Buffers the Relations Between Chronic Stress and Sympathetic Nervous System Activation 
Objectives.
Caregivers of dementia patients are at risk for developing cardiovascular disease (CVD), and this risk increases the longer they provide care. Greater perceptions that caregiving restricts social/recreational activities (i.e., activity restriction [AR]) has been associated with poorer health, and AR may exacerbate the relations between stress and health outcomes. The current study examined the interactive role of greater exposure to stress and increased AR on plasma catecholamine (CAT) levels: norepinephrine (NE) and epinephrine (EPI).
Method.
A total of 84 dementia caregivers completed a standard assessment battery, and a nurse collected blood, which was assayed for NE and EPI. Separate regressions for NE and EPI were used to determine whether the relations between years caregiving and CATs were greater in those with high versus low AR.
Results.
A significant interaction was found between years caregiving and AR in predicting resting EPI (p = .032) but not resting NE (p = .103). Post hoc analyses indicated that years caregiving was significantly associated with EPI when AR was high (p = .008) but not when AR was low (p = .799). Additionally, years caregiving was not significantly associated with NE when AR was high or low.
Discussion.
The subjective experience of AR can play an important role in determining risk for detrimental physical health outcomes, particularly CVD risk.
doi:10.1093/geronb/gbt028
PMCID: PMC3983913  PMID: 23685924
Activity restriction; Catecholamines; SNS; Stress.
16.  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
17.  Association between Hospice Care and Psychological Outcomes in Alzheimer's Spousal Caregivers 
Journal of Palliative Medicine  2013;16(11):1450-1454.
Abstract
Context
Dementia care giving can lead to increased stress, physical and psychosocial morbidity, and mortality. Anecdotal evidence suggests that hospice care provided to people with dementia and their caregivers may buffer caregivers from some of the adverse outcomes associated with family caregiving in Alzheimer's Disease (AD).
Objectives
This pilot study examined psychological and physical outcomes among 32 spousal caregivers of patients with AD. It was hypothesized that caregivers who utilized hospice services would demonstrate better outcomes after the death of their spouse than caregivers who did not utilize hospice.
Methods
The charts of all spousal caregivers enrolled in a larger longitudinal study from 2001 to 2006 (N=120) were reviewed, and participants whose spouse had died were identified. Of these, those who received hospice care (n=10) were compared to those who did not (n=22) for various physiological and psychological measures of stress, both before and after the death of the care recipient. An Analysis of Covariance (ANCOVA), with postdeath scores as the dependent variable and pre-death scores as covariates, was used for all variables.
Results
Significant group differences were found in postdeath depressive symptoms (HAM-D; F(1,29)=6.10, p<0.05) and anxiety symptoms (HAM-A; F(1,29)=5.71, p<0.05). Most psychological outcome variables demonstrated moderate effect sizes with a Cohen's d of>0.5 between groups.
Conclusions
These data suggest that hospice enrollment may ameliorate the detrimental psychological effects in caregivers who have lost a spouse with Alzheimer's Disease. Based on these pilot data, further prospective investigation is warranted.
doi:10.1089/jpm.2013.0130
PMCID: PMC3822398  PMID: 24093721
18.  Direct and Mediated Effects of Cognitive Function with Multidimensional Outcome Measures in Schizophrenia: The Role of Functional Capacity 
Although cognitive ability is a known predictor of real-world functioning in schizophrenia, there has been an expanded interest in understanding the mechanisms by which it explains real-world functioning in this population. We examined the extent to which functional capacity (i.e., skills necessary to live independently) mediated the relationship between cognitive ability and both observer and self-reported real-world functioning in 138 outpatients with schizophrenia. Functional capacity significantly mediated the relations between cognitive ability and observer rated real world functioning, but not self-reported real world functioning, with small to medium effect sizes observed for all outcomes. The role of cognitive ability in observer vs. self-reported real-world functioning may be explained by different mechanisms.
doi:10.1080/13803395.2013.828021
PMCID: PMC3789849  PMID: 23984631
Functioning; Impairment; Cognition; Self-report; Observer report
19.  A Randomized Clinical Trial of Behavioral Activation (BA) Therapy for Improving Psychological and Physical Health in Dementia Caregivers: Results of the Pleasant Events Program (PEP) 
Behaviour research and therapy  2013;51(10):623-632.
Dementia caregiving is associated with elevations in depressive symptoms and increased risk for cardiovascular diseases (CVD). This study evaluated the efficacy of the Pleasant Events Program (PEP), a 6-week Behavioral Activation intervention designed to reduce CVD risk and depressive symptoms in caregivers. One hundred dementia family caregivers were randomized to either the 6-week PEP intervention (N=49) or a time-equivalent Information-Support (IS) control condition (N=51). Assessments were completed pre- and post-intervention and at 1-year follow-up. Biological assessments included CVD risk markers Interleukin-6 (IL-6) and D-dimer. Psychosocial outcomes included depressive symptoms, positive affect, and negative affect. Participants receiving the PEP intervention had significantly greater reductions in IL-6 (p=.040), depressive symptoms (p=.039), and negative affect (p=.021) from pre- to post-treatment. For IL-6, clinically significant improvement was observed in 20.0% of PEP participants and 6.5% of IS participants. For depressive symptoms, clinically significant improvement was found for 32.7% of PEP vs 11.8% of IS participants. Group differences in change from baseline to 1-year follow-up were non-significant for all outcomes. The PEP program decreased depression and improved a measure of physiological health in older dementia caregivers. Future research should examine the efficacy of PEP for improving other CVD biomarkers and seek to sustain the intervention’s effects.
doi:10.1016/j.brat.2013.07.005
PMCID: PMC3774137  PMID: 23916631
Depression; Cardiovascular Disease; Alzheimer’s Disease; Intervention; Treatment
20.  Relations between personal mastery, chronic caregiving stress, and multiple dimensions of fatigue 
Objective
A substantial proportion of chronically stressed informal caregivers of Alzheimer’s disease patients report experiencing fatigue. The objective of this study was to examine whether personal mastery moderates the relationship between caregiving status (caregiver/non-caregiver) and multiple dimensions of fatigue.
Methods
Seventy-three elderly Alzheimer’s caregivers and 41 elderly non-caregivers completed the short form of the Multidimensional Fatigue Symptom Inventory (MFSI-SF) and questionnaires assessing mastery.
Results
Regression analyses indicate that global fatigue scores were significantly higher for caregivers (M = 38.0 ± 21.0) compared to non-caregivers (M = 18.2 ± 10.4). However, personal mastery moderated the relations between caregiving status and global fatigue (t = −2.03, df = 107, p = .045), such that for those with low mastery, caregivers’ fatigue scores were 18.1 points higher than non-caregivers, and for those with high mastery, this difference was only 7.5 points. For specific dimensions of fatigue, mastery moderated the relations between caregiving status and both Emotional (t = −2.01, df = 107, p = .047) and Physical (t = −2.51, df = 107, p = .014) fatigue. Specifically, association between caregiving status and emotional fatigue was greater when mastery was low than when mastery was high. In regards to physical fatigue, caregiving status was significantly associated with physical fatigue when mastery was low, but was not when mastery was high. Significant main effects were found between mastery and general fatigue and vigor.
Conclusion
Given the high proportion of caregivers who experience fatigue and the impact that fatigue can have on health; these findings provide important information regarding mastery’s relationship with fatigue and may potentially inform interventions aiming to alleviate fatigue in caregivers.
doi:10.1002/gps.2286
PMCID: PMC4091958  PMID: 19548267
Alzheimer’s Disease; Caregiving; Fatigue; Control; Coping; Exhaustion
21.  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
22.  Pleasant Events, Activity Restriction, and Blood Pressure in Dementia Caregivers 
Objective
A combination of high engagement in pleasurable activities and low perceived activity restriction is potentially protective for a number of health and quality of life outcomes. This study tests the newly proposed Pleasant Events and Activity Restriction (PEAR) model to explain level of blood pressure (BP) in a sample of elderly dementia caregivers.
Methods
This cross-sectional study included 66 caregivers, ≥ 55 years of age, providing in-home care to a relative with dementia. Planned comparisons were made to assess group differences in BP between caregivers reporting high engagement in pleasant events plus low perceived activity restriction (HPLR; N = 22) to those with low pleasure plus high restriction (LPHR; N = 23) or those with either high pleasure plus high restriction or low pleasure plus low restriction (HPHR/LPLR; N = 21).
Results
After adjustments for age, sex, body mass index, use of anti-hypertensive medication, physical activity, and number of health problems, HPLR participants (86.78 mm Hg) had significantly lower mean arterial pressure compared to LPHR participants (94.70 mm Hg) (p = .01, Cohen’s d=0.89) and HPHR/LPLR participants (94.84 mm Hg) (p = .023, d=0.91). Similar results were found in post-hoc comparisons of both systolic and diastolic BP.
Conclusions
This study extends support for the PEAR model to physical health outcomes. Differences in BP between the HPLR group and other groups were of large magnitude and thus clinically meaningful. The findings may inform intervention studies aimed at investigating whether increasing pleasant events and lowering perceived activity restriction may lower BP.
doi:10.1037/a0029412
PMCID: PMC3572271  PMID: 22888824
Alzheimer’s disease; dementia caregiving; behavioral activation; coping; elderly
23.  Initial validation of a computerized version of the UCSD Performance-Based Skills Assessment (C-UPSA) for assessing functioning in schizophrenia 
Schizophrenia research  2013;144(1-3):87-92.
Objective
This study aimed to validate the Computerized UCSD Performance-Based Skills Assessment (C-UPSA), a newly developed scale for assessing functional capacity in patients with schizophrenia.
Methods
The C-UPSA was administered to 21 middle-aged and older adults with schizophrenia and 20 healthy comparison (HC) subjects. Schizophrenia participants also completed the original UPSA and a symptom inventory (during a separate visit), and cognitive functioning was assessed in both groups using a brief neuropsychological screening battery.
Results
The C-UPSA total score was significantly correlated with UPSA total scores, and the magnitude of the correlation was comparable to the test-retest reliability of the original UPSA. The C-UPSA was also significantly correlated with UPSA-Brief scores and neuropsychological status among schizophrenia participants. Furthermore, the schizophrenia group scored significantly lower than the HCs on the C-UPSA. ROC curves were generated to determine the optimal C-UPSA value for discriminating between the two groups, with results indicating an optimal cutoff of 75, which is consistent with the derived cutoff from the original UPSA. The C-UPSA identified persons with schizophrenia with 95% accuracy.
Conclusions
The C-UPSA appears to be highly related to the original UPSA. It has several advantages over the standard version, including increased portability, decreased administration time, and minimization of examiner impact on participant performance. Future research would benefit from establishing this test as a clinical and research tool to effectively assess functional capacity.
doi:10.1016/j.schres.2012.12.028
PMCID: PMC3572290  PMID: 23375625
schizophrenia; computerized assessment; neuropsychology; functioning; rehabilitation; recovery
24.  Rorschach Measures of Cognition Relate to Everyday and Social Functioning in Schizophrenia 
Psychological assessment  2012;25(1):253-263.
Neurocognitive impairment and negative symptoms contribute to functional disability in people with schizophrenia. Yet, a high level of unexplained variability remains after accounting for the role of these factors. This study examined the role of thought disorder, psychological complexity, and interpersonal representations, as measured by the Rorschach, in explaining functional and social skills capacity in 72 middle-aged and older outpatients with schizophrenia (mean age = 51.2). Participants responded to the Rorschach administered using the R-Optimized administration instructions and scored using the Rorschach Performance Assessment System. Relationships with neuropsychological performance and psychopathology were also explored. Psychological complexity, which refers to a person’s cognitive capacity for problem-solving and organizing their surroundings, was correlated with functional capacity (r = .30) and social skills capacity (r = .34). Healthy interpersonal representations were correlated with positive social skills (r’s = .24 to .28). In multiple regression models, psychological complexity accounted for significant variation in functional (β = 0.23, p = 0.02) and social skills capacity (β = 0.35, p < 0.01) after controlling for neurocognitive functioning and psychopathology. These data suggest that psychological complexity plays a significant role in the functional limitations seen in schizophrenia, above and beyond the contributions of neurocognitive impairment and negative symptoms. Support was also found for the impact of healthy object relations functioning with social functioning. Clinical implications include novel information for future development of cognitive remediation treatment strategies based on a patient’s developmental level of psychological capacity and healthy interpersonal schemas.
doi:10.1037/a0030546
PMCID: PMC3578027  PMID: 23148650
functional capacity; Rorschach Performance Assessment System; thought disorder; psychological complexity; interpersonal representations
25.  Using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Effort Index to Predict Treatment Group Attendance in Patients with Schizophrenia 
In a psychosocial treatment study, knowing which participants are likely to put forth adequate effort to maximize their treatment, such as attending group sessions and completing homework assignments, and knowing which participants need additional motivation prior-to engagement in treatment is a crucial component to treatment success. This study examined the ability of the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) Effort Index (EI), a newly developed measure of suboptimal effort that is embedded within the RBANS, to predict group attendance in a sample of 128 middle-aged and older adults with schizophrenia. This study was the first to evaluate the EI with a schizophrenia sample. While the EI literature recommends a cutoff score of >3 to be considered indicative of poor effort, a cutoff of >4 was identified as the optimal cutoff for this sample. Receiver Operating Characteristics curve analyses were conducted to determine if the EI could predict participants who had high versus low attendance. Results indicated that the EI was successfully able to discriminate between group attendance, and this measure of effort appears to be most valuable as a tool to identify participants who will have high attendance. Interestingly, overall cognitive functioning and symptoms of psychopathology were not predictive of group attendance.
doi:10.1017/S1355617712001221
PMCID: PMC3568222  PMID: 23234753
Schizophrenia; Neuropsychology; RBANS; Symptom validity testing; Positive and Negative Symptoms; Receiver Operating Characteristics (ROC) curve

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