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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 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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  The use of the Theory of Planned Behavior to Predict Engagement in Functional Behaviors in Schizophrenia 
Psychiatry research  2012;205(1-2):36-42.
In Schizophrenia, low motivation may play a role in the initiation and frequency of functional behaviors. Several reviews support the efficacy of the Theory of Planned Behavior (TPB) to predict engagement in various behaviors, but little research has utilized the TPB to explain functional behavior in schizophrenia. This study tested the TPB for predicting prospective engagement in functional behaviors in a sample of 64 individuals with schizophrenia. Participants completed questionnaires assessing their attitudes toward, social norms regarding, perceived behavioral control over, and intention to engage in various functional behaviors during the upcoming week. Follow-up questionnaires assessed engagement in functional behaviors. Zero-order correlations indicated that positive attitudes, social norms, and perceived behavioral control were positively correlated with intentions to engage in functional behaviors. In turn, intentions were positively correlated with engagement in functional behaviors. Using path analysis, social norms and control were significantly related to intentions, which in turn predicted greater engagement in functional behaviors. Results suggest that patients with schizophrenia make reasoned decisions for or against engaging in functional behaviors. Skills training interventions that also target components of the TPB may be effective for increasing motivation to engage in learned behaviors.
doi:10.1016/j.psychres.2012.09.016
PMCID: PMC3538109  PMID: 23031803
Functioning; Motivation; Reasoned Action; Attitudes; Norms; Self-Efficacy
12.  A Comparison of Psychosocial Outcomes in Elderly Alzheimer’s Caregivers and Non-Caregivers 
Objectives
To conduct ananalysis of the stress, coping, and mood consequences of Alzheimer’s caregiving.
Design
Cross-sectional.
Setting
Community-based study.
Participants
Sample included 125 Alzheimer’s caregivers and 60 demographically similar older adults with non-demented spouses (i.e., non-caregivers).
Measurements
We compared caregivers and non-caregivers on stress, coping, and mood outcomes. We also examined anti-depressant use within the caregiver sample. An emphasis was placed upon effect size differences, including Cohen’s d as well as more clinically meaningful effect sizes.
Results
Caregivers were significantly more likely to endorse depressive symptoms and to meet clinically significant cutoff for depression (40% for caregivers; 5% for non-caregivers). Approximately 25% of caregivers reported taking anti-depressant medication, although 69% of these continued to experience significant symptoms of depression. Caregivers also utilized fewer positive coping and greater negative coping strategies relative to non-caregivers.
Conclusions
The number of caregivers will increase dramatically over the next two decades, and caregivers will likely seek care from primary care providers. We provide an overview of the psychological issues facing caregivers so that effective screening and treatment may be recommended.
doi:10.1016/j.jagp.2012.10.001
PMCID: PMC3376679  PMID: 23290198
13.  Leisure Activities, Caregiving Demands, and Catecholamine Levels in Dementia Caregivers 
Psychology & health  2011;27(10):1134-1149.
This study examined whether satisfaction from leisure activities moderates the relationship between caregiving demands (i.e., hours per day spent caring for a spouse with dementia) and resting levels of the catecholamines norepinephrine (NE) and epinephrine (EPI). Spousal caregivers (N=107; mean age 73.95±8.12 years) were assessed in home for plasma levels of NE and EPI, amount of care provided, and leisure satisfaction. Regression was used to determine whether leisure satisfaction moderated the relationship between hours providing care per day and catecholamine levels. A significant interaction was found between hours caregiving and leisure satisfaction for NE, but not for EPI. Post hoc regressions were conducted for both NE and EPI. At low leisure satisfaction, time spent caring for a spouse was positively associated with plasma NE (β = .41; p = .005) and EPI (β = .44; p = .003). In contrast, at high levels of satisfaction, time caregiving was not significantly associated with plasma NE (β = −.08; p = .57) or EPI (β = .23; p = .12). These findings suggest that leisure satisfaction may protect caregivers from increases in catecholamines, which have been implicated in cardiovascular risk. Further support for these findings may impact psychological treatments for distressed caregivers.
doi:10.1080/08870446.2011.637559
PMCID: PMC3346846  PMID: 22149759
leisure satisfaction; leisure activities; catecholamine; dementia caregiving; cardiovascular disease
14.  A Longitudinal Analysis of the Relations Among Stress, Depressive Symptoms, Leisure Satisfaction, and Endothelial Function in Caregivers 
Health Psychology  2012;31(4):433-440.
OBJECTIVE
Stress and depressive symptoms have been associated with impaired endothelial function as measured by brachial artery flow-mediated dilation (FMD), possibly through repeated and heightened activation of the sympathetic nervous system (SNS). Behavioral correlates of depression, such as satisfaction with leisure activities (i.e., leisure satisfaction), may also be associated with endothelial function via their association with depressive symptoms. This study examined the longitudinal associations between stress, depressive symptoms, leisure satisfaction, and endothelial function as measured by FMD.
METHODS
Participants were 116 elderly Alzheimer’s caregivers (mean age = 74.3 ± 8.1; 68% female; 87% Caucasian) who underwent three yearly assessments of FMD, stress, depressive symptoms, and leisure satisfaction. Mixed regression analyses were used to examine longitudinal relationships between constructs of interest.
RESULTS
A significant and positive association was found between leisure satisfaction and FMD (p = .050), whereas a negative relationship was found for stress (p = .017). Depressive symptoms were not associated with FMD (p = .432). Time (p < .001) and the number of years caregiving (p = .027) were also significant predictors of FMD, suggesting that FMD decreased over time and was worse the longer a participant had been a caregiver prior to study enrollment.
CONCLUSIONS
These results suggest that behavioral correlates of depression (i.e., engagement in pleasurable activities) may be related to endothelial function in caregivers, and behavioral treatments for depression may be particularly useful in improving cardiovascular outcomes in caregivers.
doi:10.1037/a0027783
PMCID: PMC3393823  PMID: 22486550
Behavioral Activation; Depression; Flow-Mediated Dilation; Stress
15.  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
16.  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
17.  Relationship between chronic stress and carotid intima-media thickness (IMT) in elderly Alzheimer’s disease caregivers 
Stress (Amsterdam, Netherlands)  2011;15(2):121-129.
The stress associated with providing care for a spouse diagnosed with Alzheimer’s disease can have adverse effects on cardiovascular health. One potential explanation is that chronic caregiving stress may contribute to the development of atherosclerosis. The purpose of this study was to determine if the duration that one has provided care is associated with degree of atherosclerotic burden, as measured by carotid artery intima-media thickness (IMT). One hundred and ten Alzheimer caregivers (mean age 74 ± 8 years, 69% female) underwent in-home assessment of carotid artery IMT via B-mode ultrasonography. Data regarding medical history, blood pressure, and multiple indicators of caregiving stress were also collected. Multiple regression indicated that duration of care was positively associated with IMT measured in the internal/bifurcation segments of the carotid artery (β = 0.202, p = 0.044) independent of risk factors such as age, gender, body mass index, smoking history, sleep quality, hypertension status, and caregiving stressors. Duration of care was positively associated with IMT in the common carotid artery, but the relationship was not significant. These findings provide more evidence of the link between chronic caregiving stress and cardiovascular disease and suggest that enduring the experience of caregiving over a period of years might be associated with atherosclerotic burden.
doi:10.3109/10253890.2011.596866
PMCID: PMC3223262  PMID: 21790484
Alzheimer’s disease; Atherosclerosis; Caregiving; Chronic Stress; Coronary Heart Disease; Intima-media thickness
18.  Effect of Chronic Dementia Caregiving and Major Transitions in the Caregiving Situation on Kidney Function: A Longitudinal Study 
Psychosomatic Medicine  2012;74(2):214-220.
Objective
To estimate the glomerular filtration rate (GFR) in relation to the chronic stress of dementia caregiving and major transitions in the caregiving situation.
Methods
We longitudinally assessed 119 elderly spousal Alzheimer’s disease (AD) caregivers and 58 non-caregiving controls for a period of up to three years (mean of 2.8 assessments per participant). Random regression models with fixed and time-variant effects for psychosocial factors, risk factors of chronic kidney disease, and caregiving transitions were used to evaluate changes over time in estimated GFR.
Results
The change in GFR did not differ between caregivers and controls during follow-up (p=.77). Further analyses revealed that GFR declined disproportionately following placement of the spouse in a nursing home at 3 months post-placement (−4.9±2.2 mL/min/1.73m2; p=.03). Post hoc analyses showed that this effect was stronger in caregivers with hypertension compared to those without hypertension (−5.7±3.1 vs. −2.4±3.4 mL/min), as well as in caregivers with diastolic BP levels at 1 standard deviation above the mean than in those with diastolic BP levels at 1 standard deviation below the mean (−8.3±2.9 vs. −1.4±2.7 mL/min).
Conclusions
Kidney function did not differ between caregivers and controls over time. However, GFR had impaired at 3 months after a major caregiving transition. As the effect of placement of the AD spouse on the decline in GFR was moderated by BP, it might be confined to caregivers who experience increased sympathetic activation post-placement.
doi:10.1097/PSY.0b013e3182408c14
PMCID: PMC3384744  PMID: 22286846
Blood pressure; caregivers; dementia; kidney disease; psychological stress
19.  Multiple Mediators of the Relations Between Caregiving Stress and Depressive Symptoms 
Aging & mental health  2012;16(1):27-38.
Objective
This study tested a model for explaining how stress is associated with depressive symptoms in a sample of spouse caregivers of patients with Alzheimer’s disease. It was hypothesized that more depressive symptoms would be significantly correlated with both “primary” caregiver stressors (i.e., care recipient problem behaviors) and “secondary” stress (i.e., role overload), but that this relationship would be significantly mediated by 4 variables: a) personal mastery, b) coping self-efficacy, c) activity restriction, and d) avoidance coping.
Method
We used an asymptotic and resampling strategy for simultaneously testing multiple mediators of the stress-to-depressive symptoms pathway.
Results
Greater stress was significantly related to more depressive symptoms. Increased stress was also associated with reduced personal mastery and self-efficacy, as well as increased activity restriction and avoidance coping. Finally, these four mediators accounted for a significant amount of the relationship between stress and depressive symptoms.
Discussion
These results suggest multiple pathways by which both primary and secondary caregiver stresses may be associated with increased depressive symptoms, and may argue for multiple treatment targets for caregiver interventions.
doi:10.1080/13607863.2011.615738
PMCID: PMC3266948  PMID: 22224706
Alzheimer’s Disease; Depression; Coping; Behavioral Activation; Self Efficacy; Stress-Process
20.  Effect of Alzheimer Caregiving on Circulating Levels of C-reactive Protein and Other Biomarkers Relevant to Cardiovascular Disease Risk: A Longitudinal Study 
Gerontology  2011;58:354-365.
Background
Providing care to a spouse with Alzheimer’s disease (AD) may contribute to cardiovascular disease (CVD). The acute phase reactant C-reactive protein is a well-established biomarker of an increased CVD risk.
Objective
To investigate the hypothesis that dementia caregiving is associated with elevated circulating levels of CRP and possibly other biomarkers of CVD risk.
Methods
We examined 118 elderly spousal Alzheimer caregivers and 51 non-caregiving controls about once a year for up to three years. Random regression models with fixed and time-variant effects for a range of covariates known to affect biomarker levels were used to evaluate changes in CRP and in twelve additional measures of inflammation, cellular adhesion, endothelial function, and hemostasis in relation to caregiving status, years of caregiving, and major transitions in the caregiving situation.
Results
During the study period longer duration of caregiving was associated with elevated CRP levels (p=0.040) and caregivers showed greater tumor necrosis factor alpha (TNF-α) levels than controls (p=0.048). Additionally, three months after the death of the AD spouse, caregivers showed a significant drop in CRP levels (p=0.003) and also in levels of soluble intercellular adhesion molecule (sICAM)-1 (p=0.008).
Conclusion
Duration of caregiving, and being a caregiver per se, were both associated with chronic low-grade inflammation as indicated by elevated CRP and TNF-α levels, respectively. Conversely, death of the AD spouse was associated with lower CRP and sICAM-1 levels. The findings indicate that chronic caregiving of those with dementia may result in increased inflammation and thereby, possibly increased CVD risk.
doi:10.1159/000334219
PMCID: PMC3425376  PMID: 22133914
Alzheimer disease; biomarkers; cardiovascular disease; caregiver; cytokines; inflammation; psychological stress
21.  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
22.  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
23.  Cardiometabolic Effects in Caregivers of Nursing Home Placement and Death of their Alzheimer Spouse 
BACKGROUND
Alzheimer’s Disease (AD) caregiving stress may contribute to increased cardiovascular disease risk in spousal caregiving through physiological changes characteristic of the metabolic syndrome (MetS).
OBJECTIVES
We tested the hypothesis that cardiometabolic risk is attenuated when caregivers are relieved from caregiving stress when the caregiving recipient transitions out of the home.
DESIGN
Longitudinal study.
SETTING
Subjects’ homes.
PARTICIPANTS
One hundred and nineteen spousal caregivers of a patient with AD and 55 non-caregiving controls (mean age 75±8 years of entire sample, 68% women).
MEASUREMENTS
Participants underwent up to three yearly assessments of MetS factors related to adiposity, dyslipidemia, hypertension, and hyperglycemia. Changes in the total number of MetS factors (range 0–5) at 3 months after caregiver transitions were evaluated using random regression models with fixed and time-variant effects for sociodemographic and health-related covariates.
RESULTS
Compared to non-caregivers, caregivers had a greater number of MetS factors over time (1.78±0.13 vs. 1.36±0.18, p=0.008), which, after the death of the spouse, dropped by 0.46±0.16 (p=0.003) being no longer different from non-caregivers; this effect was most prominently related to decreases in triglycerides (−22.2±11.0 mg/dl, p=0.032), systolic BP (−6.2±2.6 mmHg, p=0.019), and diastolic BP (−3.4±1.5 mmHg, p=0.026). Placement of the spouse decreased the number of MetS factors only in caregivers with lower levels of depressive symptoms (−0.48±0.18, p=0.010) and sleeping difficulties (−0.42±0.18, p=0.021), but not in caregivers with higher levels in these measures at post-placement.
CONCLUSION
Elevated cardiometabolic risk in caregivers decreased to the level of non-caregivers within three months of death of the AD spouse. Placement, a transition in the course of dementia caregiving, however, did not benefit cardiovascular health in highly distressed caregivers.
doi:10.1111/j.1532-5415.2011.03634.x
PMCID: PMC3384995  PMID: 22091921
Cardiovascular disease; caregivers; dementia; metabolic syndrome; psychological stress
24.  PEAR Model and Sleep Outcomes in Dementia Caregivers: Influence of Activity Restriction and Pleasant Events on Sleep Disturbances 
International psychogeriatrics / IPA  2011;23(9):1462-1469.
BACKGROUND
Sleep disturbance is a common consequence of providing care to a loved one with Alzheimer’s Disease (AD). We explored the usefulness of the Pleasant Events and Activity Restriction (PEAR) model for predicting multiple domains of sleep disturbance.
METHODS
Our sample consisted of 125 spousal Alzheimer’s disease (AD) caregivers. Participants completed the Pittsburg Sleep Quality Index (PSQI) and were queried regarding the frequency with which they engage in pleasant events and the extent to which they felt restricted in engaging in social and recreational activities in the past month. Participants were classified into one of three groups: HPLR = High Pleasant Events + Low Activity Restriction (i.e., reference group; N = 38); HPHR/LPLR = Either High Pleasant Events + High Activity Restriction or Low Pleasant Events + Low Activity Restriction (N = 52); and LPHR: Low Pleasant Events + High Activity Restriction (N = 35). These three groups were compared on the 7 subscales of the PSQI.
RESULTS
Significant differences were found between the HPLR and LPHR groups on measures of subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbance, and daytime dysfunction. Additionally, significant differences were found between the HPLR and HPHR/LPLR groups on subjective sleep quality, sleep latency, and habitual sleep efficiency, and between the HPHR/LPLR and LPHR groups on sleep disturbance and daytime dysfunction.
CONCLUSIONS
This study provides broad support for the PEAR model and suggests that interventions focusing on behavioral activation may potentially provide benefits to non-affective domains including sleep.
doi:10.1017/S1041610211000512
PMCID: PMC3199377  PMID: 21429282
Behavioral Activation; Sleep Quality; Dementia; Stress
25.  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

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