Outcome among community dwelling older adults with schizophrenia: results using five conceptual models

The Way I See It: Older Adults with Mental Illness Share Their Views of Community Life Using Photovoice

The importance of community involvement for both older adults and individuals coping with mental illness is well documented. Yet, barriers to community integration for adults with mental illness such as social stigma, discrimination, and economic marginalization are often exacerbated by increased health and mobility challenges among older adults. Using photovoice, nine older adults with mental illness represented their views of community in photographs and group discussions over a six-week period. Participant themes of community life included physical spaces, valued social roles, and access to resources in the community. Themes were anchored by older adults' perceptions of historical and cultural time comparisons between 'how things used to be' and 'how things are now.' Barriers to community integration were often related to factors such as age, mobility, and resources rather than to mental health status. Program evaluation results suggest photovoice can promote self-reflection, learning, and collaboration among older adults with mental illness.

Social pleasure in daily life: A meta-analysis of experience sampling studies in schizophrenia

Social anhedonia is considered a key feature of schizophrenia that leads to impaired social functioning. Although traditional laboratory measures assess non-current social pleasure, researchers have begun using experience sampling methods (ESM) to measure current, or consummatory, experiences of social pleasure in daily life. A recent meta-analysis examined deficits in consummatory social pleasure in schizophrenia and found vast heterogeneity in effect sizes across ESM studies. Thus, this meta-analysis aimed to extend those results by testing moderators of this effect. Meta-analysis of 14 ESM studies suggests those with psychotic disorders exhibit a moderate deficit in consummatory social pleasure compared to healthy controls. Yet, this effect was significantly moderated by the type of measure used to assess social pleasure. Measures that directly assessed positive emotional experience during socialization yielded small effects that failed to reach significance; indirect measures of other social factors related to pleasure yielded large, significant effects. This suggests daily social anhedonia observed in psychotic disorders is not due to reduced experience of positive emotion. Instead, social anhedonia may be driven by other elements of social functioning. Most clinical variables did not influence effects, but there was a trend such that patient groups with lower cognitive functioning exhibited greater pleasure deficits. Inconsistent reporting across studies limited our ability to examine other real-world variables that may contribute to deficits in social pleasure. Yet, results show different ESM items used to measure social pleasure do not assess the same construct. Future research is needed to validate ESM measures and standardize protocols across studies.

Do People With Schizophrenia Enjoy Social Activities as Much as Everyone Else? A Meta-analysis of Consummatory Social Pleasure

BACKGROUND

The "emotion paradox" of schizophrenia suggests people with schizophrenia demonstrate deficits when reporting anticipated and retrospective pleasure; yet, in-the-moment, consummatory pleasure is largely intact. It is uncertain how these findings extend to social situations. This meta-analysis aimed to (1) determine the mean difference in consummatory social pleasure between people with schizophrenia and healthy controls, and (2) examine moderators of this effect, including study design and clinical characteristics of participants.

DESIGN

A literature search using PsycINFO, Web of Science, Pubmed, and EMBASE databases was conducted. Studies measuring consummatory social pleasure using experience sampling methods and laboratory social simulations were included. Random effects meta-analyses were conducted using Hedge's g.

RESULTS

Meta-analysis of 26 studies suggests people with schizophrenia exhibited a small, significant deficit in consummatory social pleasure (g = -0.38, 90% CI [-0.53, -0.22]). There was significant heterogeneity in effect sizes; magnitude was moderated by study design and type of measure used to assess social pleasure.

CONCLUSIONS

Overall, people with schizophrenia seem to exhibit less consummatory social pleasure than controls. However, this deficit is smaller than in studies of anticipated and retrospective pleasure. Thus, consummatory social pleasure may not be quite as impaired in people with schizophrenia as traditional anhedonia research suggests. Moreover, pleasure deficits observed in people with schizophrenia may result from differences in the quality of their daily social experiences rather than differences in their capacity for social pleasure. Results have important implications for clinical interventions that address barriers to social engagement, low-pleasure beliefs, and cognitive remediation to treat schizophrenia.

Attitudes and Beliefs on Aging Among Middle-Aged and Older Adults With Serious Mental Illness

Older adults with serious mental illness (SMI) experience increased medical comorbidities, disability, and early mortality, but little is known about how they perceive the process of aging. This study explored attitudes and beliefs about aging among n = 20 middle aged and older adults (M = 59.8 years; range 47-66) with SMI in a state psychiatric hospital. We conducted semistructured interviews using the Attitudes to Ageing Questionnaire (AAQ) and analyzed narrative accounts using a grounded theory approach. The mean scores of overall attitudes toward aging and of the subscale of perception of psychological growth were both positive compared to a neutral rating (p = 0.026 and p = 0.004, respectively). Study participants rated their experience on the subscales of psychosocial loss and physical health change as neutral. Despite substantial psychiatric, medical, and functional disabilities, older adults with SMI in this study of psychiatric inpatients perceived the process of aging as generally positive, suggesting resilience and potential positive emotional growth in older age.

Subjective health-related quality of life in community-dwelling middle-aged and older adults with early-onset schizophrenia

Background: Long-term outcome in schizophrenia remains unsatisfactory due to continued premature deaths and insufficient health treatment. Subjective quality of life (SQoL) measurements hold important information and have meaningful implications regarding ways of improving general health status. This study investigated the physical and mental SQoL and associated clinical and sociodemographic outcomes among community-dwelling middle-aged and older people with early-onset schizophrenia.Materials and methods: A cross-sectional interview study where participants residing in the Region of Southern Denmark were identified through The Danish Psychiatric Central Register. Of a total of 278 eligible individuals, 59 people aged 55-82 years old participated. The SQoL measure Medical Outcomes Short Form 36 version 2 (SF36) was used. Scores were compared by age groups with normative data for the Danish population. Associated outcomes were measured using Positive And Negative Symptom Scale Remission and others.Results: Increased mental SQoL was associated with schizophrenia in remission (adjusted B 9.43, p = .001), increased Mental Health Recovery Measure score (adjusted B 0.55, p < .001) and increased GAF score (adjusted B 0.32, p < .001). Comparing with Danish Normative data, mental SQoL was reduced (p = .001) among 55-64-year olds, but presented levels similar to the general population at ages over 65 years. Physical quality of life was similar to the general population.Conclusion: Over 65-year olds with schizophrenia seemed to have SQoL similar to their age peers in the general population. Aiming treatment at achieving state of remission or recovery would be an amenable measure toward increasing mental SQoL among middle-aged people with schizophrenia.

Measuring Community Integration: Development and Psychometrics of the Community Connections and Engagement Scale

The objective of this community-based participatory research project was to develop a clinically useful, psychometrically-sound scale to measure community integration for adults with severe mental illness. Two researchers and an administrator of a behavioral health agency (BHA) recruited a group of providers, half with lived-experience of severe mental illness. Through a series of five focus groups, provider participants guided identification of four major domains of community integration and the development of 95 scale items; items and domains were reviewed by three external researchers with subject matter expertise. Initial pilot: BHA providers administered the scale to clients (n = 51) with 19 completing it twice to investigate internal consistency, test-retest reliability, and restricted variance and collinearity of items. Further piloting: providers at two BHAs administered the scale to clients (n = 178) to conduct exploratory factor analysis and analyze internal consistency. After initial pilot, 50 items remained post item reduction for restricted variance and collinearity, with Cronbach's alpha of .95 and test-retest reliability of .90. After a larger pilot, a four-factor solution emerged, aligning conceptually with the four domains as anticipated; 33 items loaded (factor loadings ≥ .4), with RMSEA of .069 and overall Cronbach's alpha of .89 (subdomains ranging .78-.86). The scale has good preliminary psychometric properties and appears to be feasible for use in BHAs for the purposes of research and evaluation, with clinical utility for assessment and treatment planning.

Community integration and related factors among people with mental illness in Japan: Multiple regression analysis stratified by social isolation level

BACKGROUD AND AIM

Community integration is an essential for people with mental illness that affects their health and quality of life. The objective of this study is to find the factors useful in improving community integration of people with mental illness.

METHODS

The study method was self-reporting questionnaires for people with mental illness living in the community. The decision tree analysis revealed that people with mental illness into high or low social isolation level strata. Multiple regression analyses stratified by using two social isolation levels were conducted.

RESULTS

Common factors among the strata were living environment of formal care accessibility and daily life activity. Specific factors for social isolation low-level stratum were self-efficacy for coping with symptoms, self-efficacy for social relationships, healthy lifestyle habits, treatment, exchange daily life information with friends and family members. Specific factors for social isolation high-level stratum were self-efficacy for daily living, self-efficacy for treatment-related behavior and satisfaction with formal care. All specific factors were positively associated with community integration.

CONCLUSIONS

The findings suggest the devising interventions to enhance community integration by social isolation level among people with mental illness.

Play provides social connection for older adults with serious mental illness: A grounded theory analysis of a 10-week exergame intervention

Introduction: The number of older adults with serious mental illness (SMI) is predicted to reach 15 million by 2030. Social isolation is known to contribute to morbidity and mortality, and those with SMI experience more social isolation than older adults in the general population. Social isolation in these older adults is complex and involves factors including organic psychopathology, effects of medications and/or other substances, medical co-morbidity, disability, and social stigma. The burgeoning field of inquiry of exergames, which are video games with gestural interfaces, for older adults has found that they are safe, effective, enjoyable, and may decrease social isolation. This qualitative study was conducted to gain insight into the effects of group exergame play on the psychosocial wellbeing of older adults with SMI.Methods: We explored the psychosocial effects of a 10-week group exergame program for 16 older adults with SMI using grounded theory methodology within a symbolic interactionist framework.Results: Participants experienced positive social contact, engaged in social attunement, and expressed motivation to take risks and face problem-solving and physical challenges. Two interrelated concepts emerged from the integrated data: Social connectedness and competence. The theoretical construct that was abducted from these concepts was that play and playfulness were the vehicle for many interacting social processes to take place.Conclusion: Group play through exergames for older adults with SMI may promote recovery and healthy aging by increasing social integration, improving self-efficacy, and promoting physical health through exercise.

Promoting Personal and Social Recovery in Older Persons with Schizophrenia: The Case of The New Club, a Novel Dutch Facility Offering Social Contact and Activities

Many older community-living persons with schizophrenia report unmet psychological and social needs. The Amsterdam-based New Club is a novel facility that intends to foster self-reliance and social participation in this group. To explore participants' and staff perceptions, a naturalistic qualitative study combined participant observation with interviews. The results illustrate how the New Club contributes to the personal and social recovery of its participants. At the personal level, attending the facility, activation and feeling accepted were valued positively. At the social level, engaging with others, experiencing a sense of community, and learning from one another's social skills were positive contributors. Next, various environmental factors proved important. The New Club demonstrates the feasibility of creating a facility that offers an accepting and non-demanding social environment to older community-living individuals with severe mental illnesses. It may offer a suitable alternative for the more demanding psychotherapeutic interventions offered to younger populations.

Utility of functioning measures in the prediction of independent living status in older adults with serious mental illness

OBJECTIVE

The objective of the study was to compare the predictive utility of three commonly used functioning measures for people with serious mental illness in the prediction of independent living status.

METHODS

We conducted a secondary data analysis from the Helping Older People Experience Success study with adults aged 50 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N = 183).

RESULTS

Total scores for the Independent Living Skills Survey, Multnomah Community Ability Scale, and UCSD Performance-Based Skills Assessment were modestly inter-correlated. For the overall sample, greater independent living status at baseline and 1-year follow-up was predicted by higher baseline functioning scores on both the self-reported Independent Living Skills Survey and the UCSD Performance-Based Skills Assessment. However, by diagnostic subgroup, independent living status at 1-year follow-up was only predicted by the Independent Living Skills Survey for affective disorders and by the UCSD Performance-Based Skills Assessment for schizophrenia-spectrum disorders. For the total sample, the Independent Living Skills Survey was associated with self-efficacy and employment status. Neither the Independent Living Skills Survey nor UCSD Performance-Based Skills Assessment was associated with medical or psychiatric hospitalizations or with subjective physical or mental health status.

CONCLUSIONS

These commonly used functioning measures for people with serious mental illness examine different aspects of functioning. The choice of functional measurement should be based on the population under study and intervention goals. Copyright © 2017 John Wiley & Sons, Ltd.

Comparison of self-rated and objective successful ageing in an international cohort

Understanding predictors of successful ageing is essential to policy development promoting quality-of-life of an ageing population. Initial models precluded successful ageing in the presence of chronic disease/functional disability; however, this is discrepant with self-reported successful ageing. Indicators of social, psychological and physical health in 1,735 people aged 65–74, living in Canada, Columbia, Brazil or Albania, were analysed in the International Mobility in Ageing Study. Multiple logistic regression analysis was performed to estimate the change in self-rated successful ageing in relation to physical health, depression, social connectedness, resilience and site, while controlling for age, gender and income sufficiency. Sixty-five per cent of participants self-rated as ageing successfully; however, this was significantly different across sites (p < 0.0005, range 17–85%) and gender (p = 0.019). Using objective measures, 6 per cent were classified as ‘successful’, with significant variability amongst sites (p < 0.0005, range 0–12%). Subjective successful ageing was associated with fewer (not absence of) chronic diseases, absence of depression and less dysfunction in activities of daily living, but not with objective measures of physical dysfunction. Social connectedness and resilience also aligned with self-rated successful ageing. Traditional definitions of objective successful ageing are likely too restrictive, and thus, do not approximate self-rated successful ageing. International differences suggest that site could be a surrogate for variables other than physical/mental health and social engagement.

Physical Health, Medication, and Healthcare Utilization among 70-Year-Old People with Schizophrenia: A Nationwide Danish Register Study

OBJECTIVES

In light of the excess early mortality in schizophrenia, mainly due to physical illnesses, we investigated medical comorbidity, use of medication, and healthcare utilization among individuals with schizophrenia who survived into older ages to uncover potential factors contributing to their longevity.

DESIGN

A nationwide register-based case-control study comparing 70-year-olds with and without schizophrenia.

SETTING

Cases were drawn from the Danish Psychiatric Central Register. Age- and sex-matched controls were drawn from the general population via the Civil Registration System.

PARTICIPANTS

All Danish inhabitants who were diagnosed and registered with early onset schizophrenia in 1970-1979 and still alive at age 70 years. Controls alive at age 70 years.

MEASUREMENTS

Chronic medical comorbidity, medications, and inpatient and outpatient healthcare utilization extracted from Danish healthcare registers.

RESULTS

Older adults with schizophrenia did not differ from controls with regard to registered chronic medical illnesses, but were significantly less likely to receive medication for cardiovascular diseases (OR: 0.65; 99.29% CI: 0.50, 0.83) and more likely to be treated with analgesics (OR: 1.46; 99.29% CI: 1.04, 2.05). Overall, hospital admissions and number of days hospitalized were equal to controls, but with significantly fewer general medical outpatient contacts (RR: 0.37; 98.75% CI: 0.24, 0.55).

CONCLUSIONS

Because the literature suggests that excess mortality continues into old age, it is possible that medical diseases were under-registered and/or under-treated. Focus on adequate medical treatment, in particular for cardiovascular disease, is needed. Future integration of psychiatric and general medical healthcare, especially outpatient care, might further optimize health outcomes for older adults with schizophrenia.

Reliability and validity of the Japanese version of the Community Integration Measure for community-dwelling people with schizophrenia

BACKGROUND

Community integration is an essential right for people with schizophrenia that affects their well-being and quality of life, but no valid instrument exists to measure it in Japan. The aim of the present study is to develop and evaluate the reliability and validity of the Japanese version of the Community Integration Measure (CIM) for people with schizophrenia.

METHODS

The Japanese version of the CIM was developed as a self-administered questionnaire based on the original version of the CIM, which was developed by McColl et al. This study of the Japanese CIM had a cross-sectional design. Construct validity was determined using a confirmatory factor analysis (CFA) and data from 291 community-dwelling people with schizophrenia in Japan. Internal consistency was calculated using Cronbach's alpha. The Lubben Social Network Scale (LSNS-6), the Rosenberg Self-Esteem Scale (RSE) and the UCLA Loneliness Scale, version 3 (UCLALS) were administered to assess the criterion-related validity of the Japanese version of the CIM.

RESULTS

The participants were 263 people with schizophrenia who provided valid responses. The Cronbach's alpha was 0.87, and CFA identified one domain with ten items that demonstrated the following values: goodness of fit index = 0.924, adjusted goodness of fit index = 0.881, comparative fit index = 0.925, and root mean square error of approximation = 0.085. The correlation coefficients were 0.43 (p < 0.001) with the LSNS-6, 0.42 (p < 0.001) with the RSE, and -0.57 (p < 0.001) with the UCLALS.

CONCLUSIONS

The Japanese version of the CIM demonstrated adequate reliability and validity for assessing community integration for people with schizophrenia in Japan.

Successful aging: considering non-biomedical constructs

OBJECTIVES

Successful aging continues to be applied in a variety of contexts and is defined using a number of different constructs. Although previous reviews highlight the multidimensionality of successful aging, a few have focused exclusively on non-biomedical factors, as was done here.

METHODS

This scoping review searched Ovid Medline database for peer-reviewed English-language articles published between 2006 and 2015, offering a model of successful aging and involving research with older adults.

RESULTS

Seventy-two articles were reviewed. Thirty-five articles met the inclusion criteria. Common non-biomedical constructs associated with successful aging included engagement, optimism and/or positive attitude, resilience, spirituality and/or religiosity, self-efficacy and/or self-esteem, and gerotranscendence.

DISCUSSION

Successful aging is a complex process best described using a multidimensional model. Given that the majority of elders will experience illness and/or disease during the life course, public health initiatives that promote successful aging need to employ non-biomedical constructs, facilitating the inclusion of elders living with disease and/or disability.

The assessment of quality of life in clinical practice in patients with schizophrenia

The aim of the present article is to review QoL scales used in studies investigating patients with schizophrenia over the past 5 years, and to summarize the results of QoL assessment in clinical practice in these patients. Literature available from January 2009 to December 2013 was identified in a PubMed search using the key words "quality of life" and "schizophrenia" and in a cross-reference search for articles that were particularly relevant. A total of n=432 studies used 35 different standardized generic and specific QoL scales in patients with schizophrenia. Affective symptoms were major obstacles for QoL improvement in patients with schizophrenia. Though positive symptoms, negative symptoms, and cognitive functioning may be seen as largely independent parameters from subjective QoL, especially in cross-sectional trials, long-term studies confirmed a critical impact of early QoL improvement on long-term symptomatic and functional remission, as well as of early symptomatic response on long-term QoL. Results of the present review suggest that QoL is a valid and useful outcome criterion in patients with schizophrenia. As such, it should be consistently applied in clinical trials. Understanding the relationship between symptoms and functioning with QoL is important because interventions that focus on symptoms of psychosis or functioning alone may fail to improve subjective QoL to the same level. However, the lack of consensus on QoL scales hampers research on its predictive validity. Future research needs to find a consensus on the concept and measures of QoL and to test whether QoL predicts better outcomes with respect to remission and recovery under consideration of different treatment approaches in patients with schizophrenia.

New perspectives on schizophrenia in later life: implications for treatment, policy, and research

Worldwide, in the past few decades, the demographics of older people (ie, people 55 years and over) with schizophrenia have changed completely with respect to absolute numbers of people affected, the proportion of all people with the disorder, life expectancy, and residential status. The ageing schizophrenia population has created vast health-care needs and their medical comorbidity contributes to higher mortality than in the general population. Proposals to classify schizophrenia into early-onset, late-onset, and very-late-onset subtypes now should be tempered by the recognition that comorbid medical and neurological disorders can contribute to psychotic symptoms in later life. The concept of outcome has become more nuanced with an appreciation that various outcomes can occur, largely independent of each other, that need different treatment approaches. Data show that schizophrenia in later life is not a stable end-state but one of fluctuation in symptoms and level of functioning, and show that pathways to improvement and recovery exist. Several novel non-pharmacological treatment strategies have been devised that can augment the clinical options used to address the specific needs of older adults with schizophrenia.

Characteristics of Older Adults With Serious Mental Illness Enrolled in a Publicly Funded In-Home Mental Health Treatment Program

In-home mental health services for older adults will likely become increasingly utilized as the population ages. Little is known about older adults with serious mental illness who receive in-home services through the public mental health system. This study examined the demographic and clinical characteristics of this population. A total of 148 clients were included. Mood disorders were present in 75.7% and schizophrenia spectrum disorders were present in 23.6%. A history of problematic substance use was documented in 47.3% of clients and 31.8% reported suicidal ideation prior to enrollment. A total of 25% of clients utilized psychiatric emergency services during the year prior to enrollment and 15.5% of clients were hospitalized for psychiatric treatment. Older adults who receive in-home mental health services are vulnerable and have complex treatment needs.

Predicting functional remission in patients with schizophrenia: a cross-sectional study of symptomatic remission, psychosocial remission, functioning, and clinical outcome

BACKGROUND

New approaches to assess outcome in schizophrenia include multidimensional measures such as remission, cognition, psychosocial functioning, and quality of life. Clinical and psychosocial measures have been recently introduced to assess functional outcome.

OBJECTIVE

The study presented here was designed to examine the rates of symptomatic remission, psychosocial remission, global functioning, and clinical global impressions in a sample of schizophrenia outpatients in order to assess functional remission and to identify predictive factors for functional remission.

METHODS

A total of 168 consecutive Mexican outpatients receiving pharmacological treatment at the National Institute of Psychiatry in Mexico City were enrolled in a cross-sectional study. Symptomatic remission was assessed according to the definition and criteria proposed by the Remission in Schizophrenia Working Group using the Positive and Negative Symptom Scale. Psychosocial remission was assessed according to Barak criteria using the Psychosocial Remission in Schizophrenia scale. Functioning was measured with the Global Assessment of Functioning, and clinical outcome with the Clinical Global Impressions (CGI) Scale.

RESULTS

Findings showed that 45.2% of patients fulfilled the symptomatic remission criteria, 32.1% achieved psychosocial remission, and 53% reported adequate functioning. However, the combination of these three outcome criteria - symptomatic, psychosocial remission, and functioning - indicated that 14.9% of the patients achieved our predefined functional remission outcome. The logistic regression model included five predictive variables for functional remission: (1) being employed, (2) use of atypical antipsychotics, (3) lower number of medications, (4) lower negative symptom severity, and (5) lower excitement symptom severity.

CONCLUSION

The study demonstrated that symptomatic remission, psychosocial remission, and functioning could be achievable goals for a considerable number of patients. The outcome of functional remission was achieved by a minority of patients, less than 15%. New approaches should include multidimensional measures to assess functional outcome in schizophrenia research.

Metamemory with ageing in schizophrenia: a first study

The aim was to study metamemory during encoding in older schizophrenia patients. Thirteen older patients were compared to 13 healthy controls. Despite their memory impairment, older schizophrenia patients were able to assess the material accurately. They were not able, however, to adapt their learning time as efficiently as controls.

Longitudinal study of remission among older adults with schizophrenia spectrum disorder

OBJECTIVE

Although studies have found that as many as half of older community-dwelling adults with schizophrenia were in symptomatic remission, these findings had been based on cross-sectional data. This study examines longitudinal changes in symptom remission rates and predictors of remission.

METHODS

The original sample consisted of 250 persons with schizophrenia spectrum disorders aged 55 and over living in New York City who developed the disorder before age 45. Data on 104 follow-up interviews are presented. Mean follow-up was 54 months (range: 12-116 months); mean age was 61 years, 55% were male, and 55% were white. A modified version of the Remission in Schizophrenia Working Group criteria was used for determining remission status.

RESULTS

There was a nonsignificant decline in the percentage attaining remission (49% baseline, 40% follow-up); 25% were in remission at both assessments, 35% were not in remission at either assessment, 25% went from remission to nonremission, and 16% went from nonremission to remission. Four significant baseline predictors of remission were found at follow-up: higher community integration, greater number of entitlements, fewer psychotropic medications, and lower frequency of psychiatric services. Baseline remission status predicted having more total contacts at follow-up.

CONCLUSION

Older adulthood is not necessarily a quiescent period, and there is considerable fluctuation in remission status. Two social variables-community integration and entitlements-predicted remission on follow-up, thus suggesting social interventions may be especially useful strategies for this population.

Measuring social inclusion--a key outcome in global mental health

BACKGROUND

Social inclusion is increasingly recognized as a key outcome for evaluating global mental health programmes and interventions. Whereas social inclusion as an outcome is not a new concept in the field of mental health, its measurement has been hampered by varying definitions, concepts and instruments. To move the field forward, this paper reviews the currently available instruments which measure social inclusion and are reported in the literature, realizing that no single measure will be appropriate for all studies or contexts.

METHODS

A systematic literature search of English language peer-reviewed articles published through February 2013 was undertaken to identify scales specifically developed to measure social inclusion or social/community integration among populations with mental disorders.

RESULTS

Five instruments were identified through the search criteria. The scales are discussed in terms of their theoretical underpinnings, domains and/or key items and their potential for use in global settings. Whereas numerous reviewed abstracts discussed mental health and social inclusion or social integration, very few were concerned with direct measurement of the construct. All identified scales were developed in high-income countries with limited attention paid to how the scale could be adapted for cross-cultural use.

CONCLUSIONS

Social inclusion is increasingly highlighted as a key outcome for global mental health policies and programmes, yet its measurement is underdeveloped. There is need for a global cross-cultural measure that has been developed and tested in diverse settings. However, until that need is met, some of the scales presented here may be amenable to adaptation.

Management of schizophrenia in late life with antipsychotic medications: a qualitative review

Although patients with schizophrenia are reported to have excess mortality compared with the general population, many affected patients will nonetheless survive and continue to have the disorder in later life. Consequently, geriatric schizophrenia will be a significant public health concern in the years to come, and evidence-based treatment of schizophrenia in older patients is becoming an urgent issue. However, there has been a paucity of comparative data to guide selection of antipsychotics for schizophrenia in late life. The primary aim of this review was to synthesize the available evidence on management of late-life schizophrenia with antipsychotic medications; a secondary aim was to evaluate treatment resistance in this population. Accordingly, PubMed and EMBASE were searched using the keywords 'antipsychotics', 'age' and 'schizophrenia' to identify psychopharmacological studies of antipsychotics in late-life schizophrenia (last search 30 April 2011). The literature search identified 23 prospective studies of use of antipsychotics for schizophrenia in older patients (generally age ≥65 years), including eight double-blind trials. The sample size was smaller than 40 patients for 52% of the studies. Two of the double-blind studies were post hoc analyses and one was a placebo-controlled trial. In the largest double-blind study, olanzapine (n = 88, median dose 10 mg/day) and risperidone (n = 87, median dose 2 mg/day) were compared in patients not resistant to these therapies, with similar effects. There have also been several open-label trials of these two agents that have shown efficacy and tolerability in non-resistant patients. Evidence on other antipsychotics has been scarce and less robust. The gold standard for treatment-resistant schizophrenia is clozapine. However, almost all of the studies of clozapine to date have effectively excluded older patients with schizophrenia. Only one small study has evaluated clozapine (n = 24, mean dose 300 mg/day) in comparison with chlorpromazine (n = 18, mean dose 600 mg/day) in a difficult-to-treat older population; the investigators reported that both treatments were similarly efficacious. Furthermore, there has been little compelling evidence in favour of or against augmentation of antipsychotics with other psychotropic medications in the older age group. Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence. However, data on geriatric patients with schizophrenia are generally scarce, particularly for treatment-resistant subpopulations, underscoring the need for more research in this important area.

Successful aging in individuals with schizophrenia dwelling in the community: a study on attitudes toward aging and preparing behavior for old age

AIM

'Successful aging' in individuals with schizophrenia has been attracting attention. We examined two forward-looking factors of successful aging among schizophrenia patients: 'attitude toward aging' and 'preparing behavior for old age'.

METHODS

Fifty-seven middle-aged and elderly schizophrenia patients with successful aging were identified using the Attitude toward Aging Scale, the Preparing Behavior for Old Age Scale, and assessments of their cognitive function, psychiatric symptoms, social functioning and quality of life. A multiple regression analysis was used to detect determinants of attitude toward aging/preparing behavior for old age at that time ('present': community dwelling). We also analyzed predictors of successful aging using demographic/clinical data assessed 3 years previously ('past': residential care).

RESULTS

The multiple regression analysis revealed that quality of life was a significant determinant: a higher quality of life was related to a more positive attitude toward aging and less active preparing behavior. The significant predictors of preparing behavior were quality of life and the length of the hospital stay: a longer hospital stay and a higher quality of life were related to less active preparing behavior.

CONCLUSION

Quality of life and the length of the hospital stay significantly contributed to forward-looking factors of successful aging. Avoiding long hospitalization periods for patients with schizophrenia may lead to more active preparing behavior, but the improvement of quality of life may not be a sufficient condition. As schizophrenia patients have an optimistic attitude and insufficient preparing behavior, support to prepare such individuals for old age is required as part of community-based psychiatric care strategies.

Remitted but still impaired? Symptomatic versus functional remission in patients with schizophrenia

INTRODUCTION

Studies reported close associations between functional outcome and symptomatic remission as defined by the Remission in Schizophrenia Working Group. This observational study was aimed at the investigation of deficits in daily functioning, symptoms and subjective well-being in remitted and non-remitted patients with schizophrenia.

METHODS

Symptoms (PANSS), functional outcome (FROGS, GAF), subjective well-being (SWN-K) and other characteristics were assessed in 131 patients with schizophrenia (DSM-IV) within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project.

RESULTS

A significant better level of functioning was measured for remitted versus non-remitted patients, though remitted patients still showed areas with an inadequate level of functioning. Functional deficits were most often seen in social relations (40%), work (29%) and daily life activities (17%). Best functioning was assessed for self-care, self-control, health management and medical treatment. A moderate to severe level of disorganization and emotional distress was observed in 38% and impaired subjective well-being in 29% of patients defined as being in symptomatic remission.

DISCUSSION

The results confirm a close association between symptomatic remission and functional outcome. However, deficits in different areas of functioning, symptoms and well-being underline the need for combined outcome criteria for patients with schizophrenia.

Remission in schizophrenia: validity, frequency, predictors, and patients' perspective 5 years later

In March 2005, the Remission in Schizophrenia Working Group (RSWG) proposed a consensus definition of symptomatic remission in schizophrenia and developed specific operational criteria for its assessment. They pointed out, however, that the validity and the relationship to other outcome dimensions required further examination. This article reviews studies on the validity, frequency, and predictors of symptomatic remission in schizophrenia and studies on patients' perspectives. These studies have demonstrated that the RSWG remission criteria appear achievable and sustainable for a significant proportion of patients, and are related to a better overall symptomatic status and functional outcome and, to a less clear extent, to a better quality of life and cognitive performance. However, achieving symptomatic remission is not automatically concurrent with an adequate status in other outcome dimensions. The results of the present review suggest that the RSWG remission criteria are valid and useful. As such, they should be consistently applied in clinical trials. However, the lack of consensus definitions of functional remission and adequate quality of life hampers research on their predictive validity on these outcome dimensions. Future research should therefore search for criteria of these dimensions and test whether the RSWG remission criteria consistently predict a “good” outcome with respect to functioning and quality of life.

Successful aging in older adults with schizophrenia: prevalence and associated factors

OBJECTIVE

This study contrasts the prevalence of successful aging in older adults with schizophrenia with their age peers in the community and examines variables associated with successful aging in the schizophrenia group.

METHODS

The schizophrenia group consisted of 198 community-dwelling persons aged 55 years and older who developed schizophrenia before the age of 45 years. A community comparison group (N = 113) was recruited using randomly selected block groups. The three objective criteria proposed by Rowe and Kahn were operationalized using a six-item summed score. The association of 16 predictor variables with the successful aging score in the schizophrenia group was examined.

RESULTS

The community group had significantly higher successful aging scores than the schizophrenia group (4.3 versus 3.0; t = 8.36, df = 309, p <0.001). Nineteen percent of the community group met all six criteria on the successful aging score versus 2% of the schizophrenia group. In regression analysis, only two variables-fewer negative symptoms and a higher quality of life index-were associated with the successful aging score within the schizophrenia group.

CONCLUSION

Older adults with schizophrenia rarely achieve successful aging and do so much less commonly than their age peers. Only two significant variables were associated with successful aging neither of which are easily remediable. The elements that comprise the components of successful aging, especially physical health, may be better targets for intervention.

Successful cognitive and emotional aging

We review the definitions, determinants, and ways of enhancing successful cognitive and emotional aging. Objective definitions of successful aging based on physical health emphasize outcomes including freedom from disability and disease, whereas subjective definitions center on well-being, social connectedness, and adaptation. Most older people do not meet objective criteria for successful aging, while a majority meet the subjective criteria. Older people with severe mental illness are not excluded from successful aging. The determinants of successful aging include complex interactions of lifestyle behaviors and social environment with genes. Depression interferes with nearly all determinants of successful aging. Evidence-based means of enhancing successful aging include calorie restriction, physical exercise, cognitive stimulation, social support, and optimization of stress. Future directions for successful aging research and implications for geriatric psychiatry are discussed.

Psychosocial rehabilitation and quality of life for older adults with serious mental illness: recent findings and future research directions

PURPOSE OF REVIEW

The projected increase of Americans aged 65 years and older will have an unprecedented impact on the healthcare delivery system. As a result, new models to support individuals with serious mental illness (SMI) will become increasingly more important. This selective overview highlights recent reports addressing psychosocial functioning and interventions for older adults with SMI.

RECENT FINDINGS

Recently published descriptive studies suggest that poor functional outcomes and lower quality of life among older people with SMI are strongly associated with social isolation, depression, cognitive impairment, and chronic medical illness. Recent research on psychosocial interventions includes evaluations of three different models of skills training, a supported employment intervention, and cognitive remediation. This research establishes psychosocial rehabilitation as feasible and potentially effective in improving functioning and quality of life in older adults with SMI.

SUMMARY

Several important directions for future research focused on older adults with SMI are suggested by this overview. They include individually tailored rehabilitation, interventions that optimize social integration and decrease depressive symptoms, techniques that blend cognitive remediation with vocational rehabilitation, and integration of health promotion with psychosocial rehabilitation.