We previously reported a relationship between forearm resistance vessel function and global neuropsychological performance in patients with atherosclerotic vascular disease (AVD). This study was conducted to determine the relationships among vascular smooth muscle function, endothelial function, and initiation and processing speed in this sample. Participants were 80 individuals with AVD. Resistance vessel function was measured before and after infusion of vasoactive agents. Neuropsychological assessment included measures of estimated premorbid cognitive function, current global cognitive function, initiation, and processing speed. Vascular smooth muscle function was significantly associated with the initiation/processing speed composite score [R-Square Change = .152; F Change (1,71) = 16.61; p < .001], above and beyond the variance accounted for by age, education, premorbid cognitive function, and endothelium-dependent vascular function. This relationship remained significant when controlling for current level of global cognitive functioning and 10 vascular risk factors. Endothelium-dependent vascular function was not significantly associated with test performance. Decreased vascular smooth muscle function in forearm resistance vessels was significantly associated with relatively poor initiation and processing speed in individuals with AVD. With additional research, measures of vascular function might become useful in the early identification of those individuals at greatest risk for vascular-related cognitive dysfunction.
Vascular dementia; Subcortical vascular dementia; Neuropsychology; Atherosclerosis; Aging; Vascular endothelium-dependent relaxation
This study was conducted to assess gender differences in cognition in elderly individuals (N = 88; 38 women, 50 men) with atherosclerotic vascular disease (AVD) and to determine whether these were attributable to differences in vascular health. Assessments included neuropsychological testing and measurement of forearm vascular function using venous occlusion plethysmography. There was a significant female advantage on multiple neuropsychological tests. This gender effect was reduced somewhat but remained significant when controlling for education and vascular function. Our study suggests that gender differences in cognition persist into older age and are not primarily due to gender differences in vascular health.
Gender; Cognition; Vascular disease; Neuropsychology; Vascular function
This study was designed to determine the relationships between PET-based quantitative measures of cerebral blood flow and cerebrovascular reserve and neuropsychological functioning in elderly individuals with atherosclerotic vascular disease. It was hypothesized that cerebrovascular function would be significantly associated with neuropsychological functioning. Results showed that both baseline global cerebral blood flow and cerebrovascular reserve were significantly associated with global neuropsychological functioning, when controlling for age and sex. Cerebrovascular reserve was additionally associated with performance on measures of memory and attention. Additional research is needed to determine whether measures of cerebral blood flow can be used to predict cognitive decline.
The purpose of the present study was to determine whether the effect of impulsive and callous personality traits on delinquent behavior varied across neighborhood context in a population-based, statewide sample of 85,000 Iowa schoolchildren ages 10–19. Two previous studies examining the association between impulsivity and delinquency across disadvantaged and affluent neighborhoods have yielded contrasting findings. Results of the present study suggested a robust moderating effect of neighborhood context on personality risk for delinquency. The relation between impulsivity and delinquency was greater in neighborhoods low in collective efficacy compared to neighborhoods high in collective efficacy. A similar interaction was found for callous personality traits, indicating the consistency of the moderating effect of neighborhood context on personality risk for delinquency. Gender differences were also examined, and results were replicated in a holdout sample.
delinquency; neighborhood context; impulsivity; callousness; gender differences
Practice effects on cognitive tests have been shown to further characterize patients with amnestic Mild Cognitive Impairment (aMCI), and may provide predictive information about cognitive change across time. We tested the hypothesis that a loss of practice effects would portend a worse prognosis in aMCI.
Longitudinal, observational design following participants across one year.
Three groups of older adults: 1. cognitively intact (n=57), 2. aMCI with large practice effects across one week (MCI+PE, n=25), and 3. aMCI with minimal practice effects across one week (MCI−PE, n=26).
After controlling for age and baseline cognitive differences, the MCI−PE group performed significantly worse than the other groups after one year on measures of immediate memory, delayed memory, language, and overall cognition.
Although these results need to be replicated in larger samples, the loss of short-term practice effects portends a worse prognosis in patients with aMCI.
Mild Cognitive Impairment; practice effects; dementia
Background and Purpose
To compare escitalopram, problem-solving therapy (PST), and placebo, to prevent poststroke depression during 6 months after discontinuation of treatment.
We examined for depression, 33 patients assigned to placebo, 34 to escitalopram, and 41 to PST.
After controlling for age, gender, prior mood disorder, and severity of stroke, new onset major depression and Hamilton Depression scores were significantly higher 6 months after escitalopram was discontinued, compared to the PST or placebo groups.
Discontinuation of escitalopram may increase poststroke depressive symptoms.
Maternal depression affects approximately one in five women, is under-treated, and compromises infant development. In the UK, public health nurses provide an empirically supported intervention (Listening Visits or LV), to depressed postpartum women. This study evaluates the effectiveness of LV when delivered by US home visitors.
Nineteen women with depressive symptoms received LV. Pre, post, and follow-up assessments evaluated depression status, life satisfaction, and treatment acceptability.
Listening Visits were associated with a statistically and clinically significant reduction in depression, improvement in life satisfaction, and were acceptable to women.
Listening Visits show considerable promise as an effective and acceptable depression treatment.
We investigated remission from any type of substance dependence in Latinos, African Americans, and whites using the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a national sample of community adults. Analyses focused on the 4,520 participants who indicated prior-to-last-year dependence on either alcohol or drugs. Outcome was categorized as current substance dependence or abuse, current use, or abstinence. Whites reported greater likelihood of substance dependence and African Americans and Latinos are just as likely to remit as Whites, once social support and age are controlled. The outcome variable “time to remission” produced a similar pattern of results.
Recovery; Remission; Race; Ethnicity
To identify determinants of new use of the first-line SGAs associated with weight gain.
Retrospective chart review.
Outpatient and inpatient psychiatry services at a tertiary, academic medical center.
Sample of 340 consecutive patients over two time periods with major depression with psychotic features, bipolar I, bipolar II, bipolar not otherwise specified, and schizoaffective disorder.
Measurements and Main Results
Clinical and sociodemographic variables associated with new use of olanzapine, risperidone, and quetiapine were identified using univariate and multivariate logistic regression. Several clinical factors were individually associated with initiation of these SGAs: mania (OR 3.6, 95% CI 1.2–10.8), psychosis (OR 3.3, 95% CI 1.5–6.9), and inpatient treatment (OR 3.8, 95% CI 1.8–7.9). Prevalent use of lithium (OR 0.3, 95% CI 0.1–0.9) and being married (OR 0.3, 95% CI 0.1–0.8) were inversely associated. Mania, psychosis, married status, and lithium use remained independently associated on multivariate analysis. Factors related to metabolic or vascular risk were not associated with SGA initiation.
Psychiatric clinicians weigh clinical features related to mental status and acuity heavily in determining whether to initiate SGAs. However, factors related to vascular risk were not associated. Future observational studies should consider current clinical status as an important factor in determining propensity to receive antipsychotics or other acute treatments for bipolar disorder.
Antipsychotic agents; Bipolar disorder; Inpatients; Logistic models; Major Depressive Disorder; Outpatients; Propensity Score; Psychotic Disorders
In this Part 2 article of research examining a model of care in which nurses screen and counsel postpartum women for postpartum depression, acceptability of such a model to postpartum patients was evaluated with a diverse sample of American women.
Study Design and Methods
Descriptive survey of two groups: 691 predominately white postpartum women with relatively high annual incomes (Sample 1) and 132 low-income women, some of whom were ethnic minorities (Sample 2). The surveys were distributed and needed to be mailed back to the investigators. The response rate was 72% in Sample 1 and 30% in Sample 2.
The overwhelming majority in both groups (>90%) felt that it was acceptable for nurses to perform screening for postpartum depression and for nurses to do the necessary counseling. More than one-half in each sample were “definitely willing” to see a nurse for counseling. Although women in both samples had positive views, when compared with each other, women with higher incomes (Sample 1) had more positive views of nurse delivered mental health care. More than one-half in each sample were “definitely willing” to see a nurse for counseling. For Sample 1, 15% reported having taken medications for postpartum depression; in Sample 2 this number was 22.3%.
Nurses have frequent contact with postpartum women; as such, they are well positioned to provide depression screening and counseling. Nurse-delivered mental health care has the potential to obviate many barriers that prevent the detection and treatment of depression, and ultimately improve outcomes for infant and children.
Postpartum Depression; Nurses’ Role; Counseling; Patient Acceptance of Health Care
To assess nurses' views of a nursing model in which nurses screen and also treat new mothers who exhibit symptoms of depression.
Study Design and Methods
This is Part 1 of this descriptive survey (Part 2 in MCN 35(4)), in which nurses (n=520) completed a statewide survey assessing nurses' views of a model of nursing care which both screens and treats postpartum depression.
The majority “strongly agreed” or “agreed” with the statement “having nurses screen for depression using a brief screening tool is a good idea”. Most (67.1%) chose the Ob-Gyn Clinic as the appropriate site for such screening. Regarding treatment by nurses, the vast majority of nurses (93.7%) “agreed” or “strongly agreed” with the statement “nurse-delivered counseling with mildly depressed women is a good idea.” Almost one-half of the nurses already regularly provided some form of counseling and approximately three quarters were willing to participate in a counseling skills training program. Less than 1.0% (n=3) indicated that nurse-delivered counseling should not be implemented. The most frequently chosen setting for a nurse-delivered counseling program was home visits (70.6%, n=367).
Our results indicate nurse-delivered screening and treatment of postpartum women is overwhelmingly supported by this segment of US nursing professionals, and indeed, is already occurring in many instances. Nurses who have frequent contact with women during the perinatal period are well positioned to provide screening and treatment for PPD. To implement the 2 part UK model (both screening and treatment), it is necessary to develop educational programs for staff and patients, and establish screening and treatment protocols as well as referral resources for those with such a need.
Postpartum Depression; Nurses' Role; Counseling
Prenatal exposure to alcohol is associated with cognitive abnormalities that persist throughout the lifespan and are also often a focus of studies examining cognitive outcomes associated with excessive alcohol use by an individual. This study examined the effect of birth outcomes consistent with fetal alcohol exposure on associations between lifetime alcohol dependence and cognition in middle adulthood. The sample was comprised of 315 adult adoptees ranging in age from 31 to 64 years (SD = 7.20). Facial morphology, pre-morbid cognition, and current cognition were assessed. Birth parent behaviors and birth outcomes (e.g., birthweight, gestational age) were obtained from adoption agency records. Lifetime alcohol dependence was determined from the Semi-Structured Assessment of the Genetics of Alcoholism – II. Univariate associations showed significantly poorer pre-morbid and current cognition when birth parent problems, short palpebral fissures, and thin upper lips were present. Lifetime alcohol dependence was associated with lower perceptional organization, processing speed and working memory. Multivariate analyses demonstrated continued significance suggesting unique contributions of each to cognition. Evaluating the possible role of fetal alcohol exposure within studies on alcoholism can only further improve the treatment and prevention of alcohol-related problems by isolating those cognitive outcomes uniquely attributable to an individual’s consumption of alcohol.
Fetal alcohol exposure; Alcohol dependence; Cognition; Facial morphology
Assessing cognitive change in older adults is a common use of neuropsychological services, and neuropsychologists have utilized several strategies to determine if a change is “real,” “reliable,” and “meaningful.” Although standardized regression-based (SRB) prediction formulas may be useful in determining change, SRBs have not been widely applied to older adults. The current study sought to develop SRB formulas on a group of 127 community-dwelling older adults for several widely used neuropsychological measures. In addition to baseline test scores and demographic information, the current study also examined the role of short-term practice effects in predicting test scores after 1 year. Consistent with prior research on younger adults, baseline test performances were the strongest predictors of future test performances, accounting for 25%–58% of the variance. Short-term practice effects significantly added to the predictability of all nine of the cognitive tests examined (3%–22%). Future studies should continue extending SRB methodology for older adults, and the inclusion of practice effects appears to add to the prediction of future cognition.
Predicting cognition; Practice effects
Evidence-based health indicators are vital to needs-based programming and epidemiological planning. Agencies frequently make programming funds available to local jurisdictions based on need. The use of objective indicators to determine need is attractive but assumes that selection of communities with the highest indicators reflects something other than random variability from sampling error.
The authors compare the statistical performance of two heterogeneity measures applied to community differences that provide tests for randomness and measures of the percentage of true community variation, as well as estimates of the true variation. One measure comes from the meta-analysis literature and the other from the simple Pearson chi-square statistic. Simulations of populations and an example using real data are provided.
The measure based on the simple chi-square statistic seems superior, offering better protection against Type I errors and providing more accurate estimates of the true community variance.
The heterogeneity measure based on Pearson's χ2 should be used to assess indices. Methods for improving poor indices are discussed.
Understanding the impact of prior substance misuse on emergent health problems is important to the implementation of effective preventive care. This study examined 5-year incidence rates using a sample of middle-aged adult adoptees (N = 309, Mage = 44.32, SDage = 7.28). Subjects reported on health problems at two waves of study. DSM-IV diagnoses of substance misuse were obtained using a semi-structured diagnostic interview. Finally, health services utilization and perceived health status were collected. Lifetime diagnoses of marijuana and other non-marijuana substance misuse significantly predicted new occurrences of cardiovascular and metabolic disease. Alcohol misuse predicted earlier onset of cardiovascular disease among men. Marijuana and other non-marijuana drugs predicted earlier onset of CVD for men and women. Finally, marijuana and other non-marijuana drugs predicted earlier onset of metabolic disease among men. Substance misuse did not predict health services utilization despite higher rates of disease. These findings emphasize the need to assess lifetime substance misuse when evaluating health risks associated with use.
To determine whether abnormalities of impulse control persist across the course of bipolar disorder, thereby representing potential state markers and endophenotypes.
Impulse control of 108 bipolar I manic or mixed patients was measured on three tasks designed to study response inhibition, ability to delay gratification, and attention; namely a stop signal task, a delayed reward task, and a continuous performance task, respectively. Barrett Impulsivity Scale (BIS-11) scores were also obtained. Patients were then followed for up to one year and re-assessed with the same measures if they developed depression or euthymia. Healthy comparison subjects were also assessed with the same instruments on two occasions to assess measurement stability.
At baseline, bipolar subjects demonstrated significant deficits on all three tasks as compared to healthy subjects, consistent with more impulsive responding in the bipolar manic/mixed group. In general, performance on the three behavioral tasks normalized upon switching to depression or developing euthymia. In contrast, BIS-11 scores were elevated during mania and remained elevated as bipolar subjects developed depression or achieved euthymia.
Bipolar I disorder patients demonstrate deficits on laboratory tests of various aspects of impulsivity when manic, as compared to healthy subjects, that largely normalize with recovery and switching into depression. However, elevated BIS scores persist across phases of illness. These findings suggest that impulsivity has both affective-state dependent and trait components in bipolar disorder.
Bipolar disorder; BIS; impulsivity; delayed reward; inattention; response inhibition
To summarize points for consideration generated in an NIMH workshop convened to provide an opportunity for reviewers from different disciplines – specifically clinical researchers and statisticians – to discuss how their differing and complementary expertise can be well integrated in the review of intervention related grant applications.
A one day workshop was convened in October, 2004. The workshop featured panel presentations on key topics followed by interactive discussion. This manuscript summarizes the workshop and subsequent discussions, which centered on topics including: weighting the statistics/data analysis elements of an application in the assessment of the application’s overall merit; the level of statistical sophistication appropriate to different stages of research and for different funding mechanisms; some key considerations in the design and analysis portions of applications; appropriate statistical methods for addressing essential questions posed by an application; and the role of the statistician in the application’s development, study conduct, and interpretation and dissemination of results.
A number of key elements crucial to the construction and review of grant applications were identified. It was acknowledged that intervention related studies unavoidably involve trade-offs. Reviewers are helped when applications acknowledge such trade-offs and provide good rationale for choices made. Clear linkage among the design, aims, hypotheses and data analysis plan and avoidance of disconnections among these elements also strengthens applications.
Multiple points to consider when constructing intervention related grant applications were identified. The points are presented here as questions and do not reflect institute policy or comprise a list of best practices, but rather represent points for consideration.
Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.
To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication.
Design, Setting, and Participants
A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups: a double-blind placebo-controlled comparison of escitalopram (n=59) with placebo (n=58), and a nonblinded problem-solving therapy group (n=59).
Main Outcome Measures
The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressivelike episode or minor depression (ie, research criteria).
Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 min or cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4–8.2; P<.001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4–3.5; P<.001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2–3.9; P=.007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8–1.5; P=.51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.
In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.
clinicaltrials.gov Identifier: NCT00071643
This study extends existing research investigating sibling concordance on attachment by examining concordance for adult attachment in a sample of 126 genetically unrelated sibling pairs. The Adult Attachment Interview (George, Kaplan, & Main, 1985; Main, Goldwyn, & Hesse, 2003) was used to assess states of mind with regard to attachment. The average age of the participants was 39 years old. The distribution of attachment classifications was independent of adoptive status. Attachment concordance rates were unassociated with gender concordance and sibling age difference. Concordance for autonomous/non-autonomous classifications was significant at 61% as was concordance for primary classifications at 53%. The concordance rate for not-unresolved/unresolved was non-significant at 67%. Our findings demonstrate similarity of working models of attachment between siblings independent of genetic relatedness between siblings and generations (i.e., parent and child). These findings extend previous research by further implicating shared environment as a major influence on sibling similarities on organized patterns of attachment in adulthood. The non-significant concordance for the unresolved classification suggests that unresolved loss or trauma may be less influenced by shared environment and more likely to be influenced by post-childhood experiences or genetic factors.
Shared environment; adult attachment; sibling concordance; adoption; working models of attachment
Stigma and stereotyping of marginalized groups often is insidious and shows up in unlikely places, for instance in how clinical trials consider dropouts in treatment research. A surprising number of studies presume that people who do not complete the study protocol relapse and code their data as if they had been observed. There is no good statistical rationale for this treatment of missing data and numerous and more defensible alternative methods are available. We need to be mindful about our attitudes and preconceptions about the people we are intending to help. There is no good reason to continue to support science built on this scientifically indefensible stereotyping, however unintentional.
To determine whether specific aspects of impulsivity (response disinhibition, inability to delay gratification, inattention) differ between healthy and bipolar manic subjects, and whether these aspects of impulsivity were associated with each other and severity of affective symptoms.
Performance of 70 bipolar I manic or mixed patients was compared to that of 34 healthy subjects on three tasks specifically designed to study response inhibition, ability to delay gratification, and attention; namely a stop signal task, a delayed reward task, and a continuous performance task respectively. Correlations among tasks and with symptom ratings were also performed.
Bipolar subjects demonstrated significant deficits on all three tasks as compared to healthy subjects. Performance on the three tasks was largely independent. Task performance was not significantly associated with the severity of affective symptom ratings. However, measures of response inhibition and attention were sensitive to medication effects. Differences in the delayed reward task were independent of medication effects or symptom ratings. During the delayed reward task, although bipolar patients made their choices more slowly than healthy subjects, they were significantly more likely to choose a smaller, but more quickly obtained reward. Moreover performance on this task was not associated with performance on the other impulsivity measures. Manic patients showed more impulsive responding than mixed patients.
Bipolar I manic patients demonstrate deficits on tests of various aspects of impulsivity as compared to healthy subjects. Some of these differences between groups may be mediated by medication effects. Findings suggested that inability to delay gratification (i.e., delayed reward task) was not simply a result of the speed of decision making or inattention, but rather that it reflected differences between bipolar and healthy subjects in the valuation of reward relative to delay.
Bipolar disorder; impulsivity; delayed reward; inattention; response inhibition
Studies have shown that individuals with psychiatric or general medical illness can benefit from interventions designed to enhance decisional capacity for research informed consent. In some cases, interventions have been rather lengthy or complex. The current study was designed to determine whether a brief intervention could improve decisional capacity in people with schizophrenia. Thirty individuals with schizophrenia and 30 healthy comparison participants were presented with a hypothetical research scenario. Decisional capacity was assessed with the MacArthur Competence Assessment Tool–Clinical Research version. Those with schizophrenia received a brief intervention aimed at improving understanding of the research protocol, after which decisional capacity was reassessed. A neuropsychological battery and symptom rating scales were also administered. At baseline, the schizophrenia group earned significantly lower scores than the comparison group on 2 aspects of decisional capacity (understanding, appreciation). At follow-up, the schizophrenia group had improved significantly on understanding and was no longer significantly different from the comparison group on any of the 4 dimensions of decisional capacity. Follow-up analyses also showed a significant effect of the intervention on a subset of the schizophrenia group who had performed most poorly at baseline. Participants with schizophrenia earned significantly lower scores than those in the comparison group across multiple neuropsychological domains. These findings add to the existing literature indicating that brief interventions can improve decisional capacity in individuals with schizophrenia, despite the fact that the illness typically causes significant cognitive dysfunction. The use of such interventions will enable a larger number of people with schizophrenia to make informed decisions regarding research participation.
informed consent; decisional capacity; ethics; schizophrenia
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Substance Abuse Treatment, Prevention, and Policy (SATPP) is an open access, peer-reviewed international journal of original research and scholarship that focuses on policy issues in the treatment and prevention of substance use disorders. Separate and often disparate public systems deal with substance use problems as well as provide treatment and prevention. This journal will provide an environment for the exchange of ideas, new research, consensus papers, and critical reviews that bridge fields that share a common goal of reducing the problems caused by drugs and alcohol. The agenda is simple; a new forum for integrating thoughts, issues, and developments.