CD4 and CD8 counts are associated with interactions of gender and psychosocial stress

Determination of Psychological Stress, Serum Immune Parameters, and Cortisol Levels in Patients With Human Papilloma Virus

PURPOSE

Because the results of studies investigating the relation between human papilloma virus (HPV) infection and the effects of psychological stress are inconsistent, this study was conducted to expand on previous research by analyzing patient stress levels, serum immune parameters, and cortisol levels in patients with clinical HPV manifestations. It also looked for differences in clinical manifestations of HPV depending on patient level of experienced stress.

METHODS

This cross-sectional study included 213 subjects (94 women and 119 men aged ≥18 years; average age, 41 years) with clinical manifestations of HPV infection (165 subjects with extragenital manifestations and 48 with genital manifestations) who were treated at the Department of Dermatovenerology, Karlovac General Hospital, from January 1, 2012, to December 31, 2015. Psychological, neurohormonal and immune parameters (serum values of leukocytes, alpha₂-globulins, beta-globulins, albumins, and proteins), and serum cortisol levels were analyzed. Questionnaires were used to determine patients' perception of stress: the Recent Life Changes Questionnaire, the Perceived Stress Scale, and the Brief Cope Test. One group of subjects had confirmed stressful experiences, defined by the Recent Life Changes Questionnaire as a period of 1 year with at least 500 life change units; the control group included patients with no significant stressful experiences.

FINDINGS

Patients with confirmed significant stress experience had a statistically significant higher degree of perception of stress. There were no statistically significant differences in terms of the impact of stress on clinical HPV manifestations (genital and extragenital), sex, lesional duration, or recurrence. In patients with significant stress experience, significantly higher values of leukocytes (6.68 × 10⁹/L), alpha₂-globulins (6.85 g/L), and beta-globulins (7.33 g/L) were observed. Adaptive coping and a lower perception of stress significantly reduced the chances of having extragenital manifestations by 2.63 times. A higher perception of stress significantly increased the likelihood of genital manifestations.

IMPLICATIONS

Although this study found that stress increased the values of leukocytes, alpha₂-globulins, and beta-globulins, no evidence was found that it affected clinical manifestations of HPV infection. The redundancy of the immune system could account for this finding. This study is among the first to investigate the correlation between psychological, neurohormonal, and immune indicators of stress.

A Scoping Review of Literature on Sex and Gender Differences Among Dementia Spousal Caregivers

BACKGROUND AND OBJECTIVES

Sex and gender differences among dementia spousal caregivers have been investigated, but never systematically reviewed or synthesized. A synthesis of findings can help facilitate specificity in practice and in health policy development. As a first step towards such a synthesis, this scoping review reports the available evidence, identifies research gaps, and suggests possible directions for future research.

RESEARCH DESIGN AND METHODS

A scoping review methodology was used to identify articles, and to chart and analyze data. Systematic searches for published, empirical studies, with an explicit goal or hypothesis related to sex or gender differences were conducted in seven databases.

RESULTS

Sixty-one studies met inclusion criteria. Most (n = 45) were quantitative, cross-sectional studies. Caregivers included in the studies were generally 61-70 years old, Caucasian, middle-class, and highly educated. The most extensively investigated differences are: depression, burden, objective physical health, and informal supports.

DISCUSSION AND IMPLICATIONS

This scoping review is the first to summarize and critique the research on sex and gender differences that are specific to dementia spousal caregivers. The review can be used by researchers to make decisions regarding future systematic reviews and primary studies. To further strengthen the evidence base, future studies may benefit from including more caregivers of ethnic minorities, using more qualitative, longitudinal, or experimental designs, and focusing on variables needed to inform caregiving models and theories. Overall, this scoping review contributes to furthering gender-sensitive practices and policies that are better tailored to the specific needs of this population.

Is Family Caregiving Associated With Inflammation or Compromised Immunity? A Meta-Analysis

BACKGROUND AND OBJECTIVES

Family caregiving stress has been widely reported to have negative effects on circulating biomarkers of immune system function and inflammation. Our goals were to systematically review this literature and conduct a meta-analysis on the extracted effects.

RESEARCH DESIGN AND METHODS

A systematic search of published studies comparing caregivers and noncaregivers on biomarkers measured from blood samples was conducted in the PubMed, Embase, and Cochrane databases. This search identified 2,582 articles and abstracts. After removing duplicative papers and studies not meeting inclusion criteria, 30 articles were identified that reported analyses on 86 relevant biomarkers from 1,848 caregivers and 3,640 noncaregivers.

RESULTS

Random-effects models revealed an overall effect size across all biomarkers of 0.164 SD units (d). A slightly larger overall effect (d = 0.188) was found for dementia caregivers only. Immune system comparisons yielded somewhat larger differences than inflammation comparisons. Most studies used small convenience samples, and effect sizes were larger for studies with moderate or high bias ratings than for studies with low bias ratings. No significant associations were found in studies that used population-based samples.

DISCUSSION AND IMPLICATIONS

Caregivers had small but significantly reduced immune system functioning and greater inflammation than noncaregivers, but associations were generally weak and of questionable clinical significance. The absence of clear associations from low bias studies and population-based studies underscores concerns with possible selection biases in many of the convenience samples. Population-based studies that assess biomarkers before and after the onset of caregiving might add much clarity to this literature.

Alzheimers' disease and caregiving: a meta-analytic review comparing the mental health of primary carers to controls

OBJECTIVES

To quantitatively review the literature comparing depressed mood, anxiety and psychological distress in caregivers (CGs) of older adults with Alzheimer's disease (AD) with non-caregivers (NCGs) Methods: Eighteen independent studies comparing AD CGs (N = 2378) with NCGs (N = 70,035) were evaluated in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Standardised mean differences (Hedges' g) with associated 95% confidence intervals and p-values were calculated using a random-effects model.

RESULTS

Studies generally conformed to STROBE criteria in terms of their methodological and procedural detail, although data management issues that may contribute to methodological bias were identified. Pooled effect estimates revealed medium to large group differences in depression (g_w = 1.01 [CI: 0.73, 1.29] p < 0.01) and anxiety (g_w = 0.64 [CI: 0.39, 0.89] p < 0.01): AD caregivers reported higher symptom severity. Gender was a significant moderator: female caregivers experienced poor self-reported mood (g_w = 1.58 [CI: 1.11, 2.05], p < 0.01), although this analysis was limited in power given the small number of contributing studies.

DISCUSSION

Caregivers of patients with AD experience poor mental health in comparison to the general population, with female caregivers being disproportionately affected. Further exploration of the psychosocial variables that contribute to these group differences is needed to inform effective support services and, in turn, help caregivers manage the emotional demands of AD.

A systematic review of the psychobiological burden of informal caregiving for patients with dementia: Focus on cognitive and biological markers of chronic stress

As the physiological impact of chronic stress is difficult to study in humans, naturalistic stressors are invaluable sources of information in this area. This review systematically evaluates the research literature examining biomarkers of chronic stress, including neurocognition, in informal dementia caregivers. We identified 151 papers for inclusion in the final review, including papers examining differences between caregivers and controls as well as interventions aimed at counteracting the biological burden of chronic caregiving stress. Results indicate that cortisol was increased in caregivers in a majority of studies examining this biomarker. There was mixed evidence for differences in epinephrine, norepinephrine and other cardiovascular markers. There was a high level of heterogeneity in immune system measures. Caregivers performed more poorly on attention and executive functioning tests. There was mixed evidence for memory performance. Interventions to reduce stress improved cognition but had mixed effects on cortisol. Risk of bias was generally low to moderate. Given the rising need for family caregivers worldwide, the implications of these findings can no longer be neglected.

PTSD is associated with an increase in aged T cell phenotypes in adults living in Detroit

BACKGROUND

Psychosocial stress is thought to play a key role in the acceleration of immunological aging. This study investigated the relationship between lifetime and past-year history of post-traumatic stress disorder (PTSD) and the distribution of T cell phenotypes thought to be characteristic of immunological aging.

METHODS

Data were from 85 individuals who participated in the community-based Detroit Neighborhood Health Study. Immune markers assessed included the CD4:CD8 ratio, the ratio of late-differentiated effector (CCR7-CD45RA+CD27-CD28-) to naïve (CCR7+CD45RA+CD27+CD28+) T cells, the percentage of KLRG1-expressing cells, and the percentage of CD57-expressing cells.

RESULTS

In models adjusted for age, gender, race/ethnicity, education, smoking status, and medication use, we found that past-year PTSD was associated with statistically significant differences in the CD8+ T cell population, including a higher ratio of late-differentiated effector to naïve T cells, a higher percentage of KLRG1+ cells, and a higher percentage of CD57+ cells. The percentage of CD57+ cells in the CD4 subset was also significantly higher and the CD4:CD8 ratio significantly lower among individuals who had experienced past-year PTSD. Lifetime PTSD was also associated with differences in several parameters of immune aging.

CONCLUSIONS

PTSD is associated with an aged immune phenotype and should be evaluated as a potential catalyzer of accelerated immunological aging in future studies.

Filial Caregiving is Associated with Greater Neuroendocrine Dysfunction: Evidence from the 2005 National Survey of Midlife in the U.S

Objectives:

This study examined associations between providing caregiving for a biological or adoptive parent and clinically assessed biological risk factors (allostatic load and its three subscales—inflammatory dysfunction, metabolic dysfunction, and neuroendocrine dysfunction), as well as moderation of these associations by gender.

Methods:

Regression models were estimated using telephone and self-report data from 962 men and women who participated in the National Survey of Midlife in the United States in 2005.

Results:

Filial caregivers demonstrated higher levels of neuroendocrine dysfunction. No gender difference in biological risks was found.

Discussion:

Filial caregiving is the most prevalent form of family caregiving, and results indicating the presence of greater neuroendocrine dysfunction among filial caregivers in contrast to noncaregivers suggest an important public health concern. Future research needs to continue to examine different relationship types of caregivers and include a range of biological risk measurement to further the understanding of how family caregiving is linked to biological health risks.

Anger expression and natural killer cell activity in family caregivers participating in a physical activity trial

Associations between psychological functioning and natural killer cell activity (NKA) were examined in 23 older (62.2 ± 7.5 years) family caregivers randomized to a moderate intensity four-month exercise program or to a wait-list control condition. At baseline, although NKA was related to anger-control (r = -.42; trend p < .06) and anger-out (r = .50; p < .03), it was not related to depression, anxiety, perceived stress, or caregiver burden. After controlling for baseline NKA, changes in anger-control explained 14 percent of the variance in NKA four months later. Decreases in anger-control predicted increases in NKA. Group assignment (exercise vs control) was unrelated to changes in NKA over the four-month period; however, the study was not powered to detect this effect. These results are consistent with reported relationships of anger expression with other physiological measures, and extend the importance of anger expression to immune functioning in older family caregivers.

Does Gender Moderate Factors Associated with Whether Spouses Are the Sole Providers of IADL Care to Their Partners?

We explored whether gender moderated the influence of other factors on solo spousal caregiving. The subsample (N = 452) from the AHEAD study included elderly care recipients (CRs) receiving IADL assistance and their spouses. Logistic regression modeled the likelihood of solo spousal IADL care. Gender moderation was tested by product terms between CRs' gender and measures of partners' health, potential helpers, and sociodemographic characteristics. As numbers of CRs' IADLs and couples' proximate daughters increased, wives less often received care solely from their husbands, but husbands' receipt of care from their wives was unaffected. Age differences between spouses and CRs affected solo spousal caregiving to wives and husbands in opposite ways. Regardless of gender, CRs' number of ADL limitations and spouses with IADL or ADL limitations reduced the likelihood of solo spouse care. Identifying circumstances influencing solo spouse caregiving differently among couples with frail wives and husbands facilitates gender sensitive services.

Immune Measures in Behavioral Medicine Research: Procedures and Implications

Immune system activity is heavily influenced by the central nervous system. These interactions provide us the means to study mind–body interactions and how they affect health. In general, measures of immune system activity can be divided into two categories: those that are evident in the circulation and those that need to be elicited. For example, leukocytes can be collected from the circulation, counted, and their function accessed in cell culture. To test the ability of the immune system to respond to an experimental challenge more directly, studies involving wound healing, or involving the response to an infectious agent, can be performed. The purpose of this chapter is briefly to describe immune assays that are commonly employed in behavioral medicine research, including a rationale for their use as well as a brief description of the methodology. This chapter also describes previous studies in which circulatory and elicited immune measures have been studied in human subjects experiencing different psychological stressors, with an emphasis on studies involving medical students experiencing academic stress and caregivers of a spouse with Alzheimer’s disease. Finally, the chapter discusses the important role that the employment of animal models can play in studies of stress and health and in defining how nervous system activity can influence the immune response.

Effects of gender and dementia severity on Alzheimer's disease caregivers' sleep and biomarkers of coagulation and inflammation

BACKGROUND

Being a caregiver for a spouse with Alzheimer's disease is associated with increased risk for cardiovascular illness, particularly for males. This study examined the effects of caregiver gender and severity of the spouse's dementia on sleep, coagulation, and inflammation in the caregiver.

METHODS

Eighty-one male and female spousal caregivers and 41 non-caregivers participated (mean age of all participants 70.2 years). Full-night polysomnography (PSG) was recorded in each participants home. Severity of the Alzheimer's disease patient's dementia was determined by the Clinical Dementia Rating (CDR) scale. The Role Overload scale was completed as an assessment of caregiving stress. Blood was drawn to assess circulating levels of D-dimer and Interleukin-6 (IL-6).

RESULTS

Male caregivers who were caring for a spouse with moderate to severe dementia spent significantly more time awake after sleep onset than female caregivers caring for spouses with moderate to severe dementia (p=.011), who spent a similar amount of time awake after sleep onset to caregivers of low dementia spouses and to non-caregivers. Similarly, male caregivers caring for spouses with worse dementia had significantly higher circulating levels of D-dimer (p=.034) than females caring for spouses with worse dementia. In multiple regression analysis (adjusted R(2)=.270, p<.001), elevated D-dimer levels were predicted by a combination of the CDR rating of the patient (p=.047) as well as greater time awake after sleep onset (p=.046).

DISCUSSION

The findings suggest that males caring for spouses with more severe dementia experience more disturbed sleep and have greater coagulation, the latter being associated with the disturbed sleep. These findings may provide insight into why male caregivers of spouses with Alzheimer's disease are at increased risk for illness, particularly cardiovascular disease.

The impact of environmental risk factors on HIV-associated cognitive decline in children

Both the human immunodeficiency virus (HIV) and environmental stress have been independently associated with decreased cognitive functioning in children. Given that they are also known to have a strong relationship with each other, the present study sought to test the hypothesis that children in conditions of high environmental risk would be at greater risk for the cognitive complications related to immunosuppression. A retrospective review was conducted to examine the records of 141 children treated at a large pediatric AIDS clinic from 1993 to 2000. CD4+ lymphocyte levels were recorded from laboratory results and IQ scores were recorded from routine psychological evaluations. Key indicators of environmental risk were collected and combined into one measure of overall environmental risk. Pearson product moment correlations were conducted to examine the relationship between environmental risk, age-adjusted CD4 and IQ. Results indicated a significant correlation between CD4 and IQ, with higher levels of immunocompetence predicting higher IQ scores. When subjects were dichotomized based on their environmental risk score, there was no relationship between CD4 count and IQ in the low environmental risk group. In contrast, CD4 was positively associated with IQ in the high environmental risk group. It is proposed that this may be due to gp120 levels in immunocompromised children being particularly toxic to the hippocampus and cortex under conditions of high stress but not so under conditions of low stress.

Caregiving, mortality, and mobility decline: the Health, Aging, and Body Composition (Health ABC) Study

BACKGROUND

Although caregivers report more stress than noncaregivers, few studies have found greater health decline in older caregivers. We hypothesized that caregivers may be more physically active than noncaregivers, which may protect them from health decline.

METHODS

The sample included 3075 healthy adults from the Health, Aging, and Body Composition (Health ABC) Study. They were aged 70 to 79 years in April 1997 to June 1998 and resided in Memphis, Tennessee, or Pittsburgh, Pennsylvania. Caregivers (680 [22.1%]) were participants who provided regular care or assistance for a child or a disabled or sick adult. Outcomes included all-cause mortality and incident mobility limitation (defined as difficulty walking one-quarter mile or climbing 10 steps on 2 consecutive semiannual contacts) during 8 years. Total physical activity included daily routine, exercise, and caregiving activity.

RESULTS

Overall, 20.6% of caregivers died and 50.9% developed mobility limitations vs 22.0% and 48.9% of noncaregivers, respectively. Associations differed by race and sex. Mortality and mobility limitation rates were 1.5 times higher in white caregivers (eg, among white female caregivers, adjusted hazard ratio for mortality, 1.6; 95% confidence interval, 1.0-2.5) but not for black female caregivers vs noncaregivers (adjusted hazard ratio for mortality, 0.9; 95% confidence interval, 0.5-1.4). Physical activity mediated these associations in most race-sex groups. High-intensity caregivers (ie, caregiving > or =24 hours per week) had elevated rates of decline when adjusted for physical activity but lower rates when not adjusted for activity.

CONCLUSION

Older white caregivers have poorer health outcomes than black female caregivers. Physical activity appears to mask the adverse effects of high-intensity caregiving in most race-sex groups.

Parental stress and childhood wheeze in a prospective cohort study

BACKGROUND

Although studies indicate that psychological stress is linked with asthma morbidity, it is unknown whether stress is associated with the incidence of asthma symptoms.

METHOD

In a cohort of 5- to 6-year-old school children participating in the southern California Children's Health Study, we evaluated parent-reported wheeze in the child using a standardized questionnaire and perceived parental stress at study entry. Wheeze in the child was evaluated one year later. Analyses were restricted to children without asthma at study entry (N = 2,888, of whom 286 had wheeze at follow-up).

RESULTS

There was an increase in wheeze across an interquartile range of parent stress (odds ratio [OR] 1.18; 95% confidence interval [CI] 0.99, 1.42). Parent stress was associated with wheeze among children with no parental asthma (OR 1.24; CI 0.99, 1.55) and among boys (OR 1.34; CI 1.04, 1.74), but not among girls or children with parental asthma. Among boys with no parental asthma there was a strong dose-response relationship, and in the top quartile of stress the OR was 2.76 (CI 1.39, 5.51) compared to the bottom quartile.

CONCLUSION

Parental stress increases the risk of childhood wheeze among children with no parental history of asthma, especially among boys. These results suggest that the influence of psychosocial factors on asthma, such as stress and social environment, deserve increased attention.

Comparative outcomes of two distance-based interventions for male caregivers of family members with dementia

Data are presented on a preliminary study investigating the efficacy of 2 distance-based psychosocial interventions (N = 32) for male family dementia caregivers. Male caregivers were randomly assigned to either a basic education intervention (ie, educational booklet and biweekly check-in telephone calls) or a video intervention (ie, set of 10 videos, an accompanying workbook, and weekly telephone coaching sessions using behavioral strategies to manage challenging caregiving situations). Results did not support the greater efficacy of the video condition in reducing psychosocial distress (eg, negative affect, upset and annoyance following behavior problems) or increasing positive affect or caregiving self-efficacy. There was, however, a statistically significant effect for postintervention improvement in both the video/coaching and the educational booklet/check-in conditions. Potential reasons for the lack of differential treatment effects are discussed, along with implications for recruitment of male dementia caregivers.

A review of studies of the Hamilton depression rating scale in healthy controls: implications for the definition of remission in treatment studies of depression

The Hamilton Rating Scale for Depression (HRSD) is the most commonly used symptom severity scale to evaluate the efficacy of antidepressant treatment. On the basis of an expert consensus panel, an HRSD score of < or = 7 was recommended as a cutoff to define remission. Since that recommendation, little empirical work has been conducted to confirm the validity of this threshold. One approach toward determining a cutoff score for defining remission is to establish the range of values for healthy controls. We therefore conducted a literature review of studies of the HRSD in healthy controls to determine the normal range of values. Studies of the HRSD in healthy control groups were identified in two ways. First, a MEDLINE search for the years 1966 to 2002 was conducted using the key words Hamilton, depression, and controls, and articles were reviewed. Second, the 69 studies included in two review articles written by the authors were examined. We identified 27 studies that included data on the HRSD for 1014 healthy controls. Across all studies, the weighted mean (SD) HRSD score, adjusting for sample size, was 3.2 (3.2; 95% CI, 3.0 to 3.4). HRSD scores were similar in geriatric and nongeriatric samples, and in men and women. Because HRSD scores in healthy controls are more likely to follow a skewed than a normal distribution, based on a mean of 3.2 and a SD of 3.2, at least 84% of healthy controls scored 7 or less on the HRSD, and 97.5% scored 10 or less. Thus, these results can be taken as support for the recommended cutoff of 7 on the HRSD to define remission. The results can also be used for normative comparisons in which posttreatment group mean scores are compared with mean scores from normative samples.

Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry

The present report meta-analyzes more than 300 empirical articles describing a relationship between psychological stress and parameters of the immune system in human participants. Acute stressors (lasting minutes) were associated with potentially adaptive upregulation of some parameters of natural immunity and downregulation of some functions of specific immunity. Brief naturalistic stressors (such as exams) tended to suppress cellular immunity while preserving humoral immunity. Chronic stressors were associated with suppression of both cellular and humoral measures. Effects of event sequences varied according to the kind of event (trauma vs. loss). Subjective reports of stress generally did not associate with immune change. In some cases, physical vulnerability as a function of age or disease also increased vulnerability to immune change during stressors.

Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry

The present report meta-analyzes more than 300 empirical articles describing a relationship between psychological stress and parameters of the immune system in human participants. Acute stressors (lasting minutes) were associated with potentially adaptive upregulation of some parameters of natural immunity and downregulation of some functions of specific immunity. Brief naturalistic stressors (such as exams) tended to suppress cellular immunity while preserving humoral immunity. Chronic stressors were associated with suppression of both cellular and humoral measures. Effects of event sequences varied according to the kind of event (trauma vs. loss). Subjective reports of stress generally did not associate with immune change. In some cases, physical vulnerability as a function of age or disease also increased vulnerability to immune change during stressors.

Sex differences in immune responses and immune reactivity to stress in adolescents

The immune system is the body's major defense mechanism against disease. However, psychosocial factors, such as stress, can modulate various immune responses. Although they have been examined in adult humans and other animals, sex differences in immune responses and immune reactivity to stress have rarely been examined in adolescents, particularly comparing healthy and asthmatic adolescents. In 151 healthy and asthmatic high school adolescents (91 females and 60 males), natural killer cell (NK) cytotoxicity, polymorphonuclear leukocyte (PMN) superoxide release, lymphocyte proliferative responses, and CD subsets were measured twice: once during mid-semester and again during final examinations. There was little difference in these measures between healthy and asthmatic adolescents. Similarly, only sex difference was noted in NK cytotoxicity at a 25:1 effector-to-target cell ratio, with males showing significantly higher responses than females. For PMN superoxide release, females significantly increased their responses during final examinations, whereas males demonstrated no changes. For lymphocyte proliferative responses, both females and males increased their responses during final examinations, but the magnitude of increase was much greater in males. Furthermore, racial comparisons indicated that African American adolescents (n = 16), as compared with Caucasian adolescents (n = 128), had significantly higher responses in PMN superoxide release to N-Formyl-Met-Leu-Phe (FMLP) activation during mid-semester and lymphocyte proliferative responses at both time points. Nevertheless, the overall findings indicate limited differences in immune responses and immune reactivity to stress in adolescents between males and females, healthy and asthmatic adolescents, and Caucasians and African Americans. However, further investigations with larger samples are warranted.

Is caregiving hazardous to one's physical health? A meta-analysis

Caring for a family member with dementia is generally regarded as a chronically stressful process, with potentially negative physical health consequences. However, no quantitative analysis has been conducted on this literature. The authors combined the results of 23 studies to compare the physical health of caregivers with demographically similar noncaregivers. When examined across 11 health categories, caregivers exhibited a slightly greater risk for health problems than did noncaregivers. However, sex and the health category assessed moderated this relationship. Stronger relationships occurred with stress hormones, antibodies, and global reported health. The authors argue that a theoretical model is needed that relates caregiver stressors to illness and proffers moderating roles for vulnerabilities and resources and mediating roles for psychosocial distress and health behaviors.

Alzheimer's disease: usefulness of the Family Strain Questionnaire and the Screen for Caregiver Burden in the study of caregiving-related problems

OBJECTIVES

The economic and psychosocial impacts of Alzheimer's disease (AD) on caregivers are so well documented that they have stimulated socioeconomic regulations that are international in scope. In Italy caregivers have the right to receive economic and psychosocial aid. However, to distribute such aid the needs of caregivers, must be properly assessed. Here we have attempted to integrate two measures, the Family Strain Questionnaire (FSQ) and the Screen for Caregiver Burden (SCB), in order to evaluate caregiver needs that are both general and specific to AD.

MATERIAL AND METHODS

The SCB and FSQ were administered to 91 primary caregivers of home-based patients with AD. Caregivers also were asked to rate the activities of daily living of their care recipients, the latter of which were administered the Mini-Mental State Examination.

RESULTS

The SCB and FSQ provide different, but complementary assessments of the needs of AD caregivers. The SCB identifies situations that are potentially stressful to AD caregivers and the FSQ identifies the needs of specific caregivers (e.g. men vs women, spouses vs children, unemployed vs employed).

CONCLUSION

Together these measures may help government agencies to assess caregiver needs beyond those assessed by each individual measure.

Psychoneuroimmunology and psychosomatic medicine: back to the future

OBJECTIVE

Although psychological modulation of immune function is now a well-established phenomenon, much of the relevant literature has been published within the last decade. This article speculates on future directions for psychoneuroimmunology research, after reviewing the history of the field.

METHODS

This review focuses on human psychoneuroimmunology studies published since 1939, particularly those that have appeared in Psychosomatic Medicine. Studies were clustered according to key themes, including stressor duration and characteristics (laboratory stressors, time-limited naturalistic stressors, or chronic stress), as well as the influences of psychopathology, personality, and interpersonal relationships; the responsiveness of the immune system to behavioral interventions is also addressed. Additionally, we describe trends in populations studied and the changing nature of immunological assessments. The final section focuses on health outcomes and future directions for the field.

RESULTS

There are now sufficient data to conclude that immune modulation by psychosocial stressors or interventions can lead to actual health changes, with the strongest direct evidence to date in infectious disease and wound healing. Furthermore, recent medical literature has highlighted a spectrum of diseases whose onset and course may be influenced by proinflammatory cytokines, from cardiovascular disease to frailty and functional decline; proinflammatory cytokine production can be directly stimulated by negative emotions and stressful experiences and indirectly stimulated by chronic or recurring infections. Accordingly, distress-related immune dysregulation may be one core mechanism behind a diverse set of health risks associated with negative emotions.

CONCLUSIONS

We suggest that psychoneuroimmunology may have broad implications for the basic biological sciences and medicine.

Lymphocyte proliferation is associated with gender, caregiving, and psychosocial variables in older adults

We examined lymphocyte responses to mitogens [phytohemagglutinin (PHA), concanavalin A, pokeweed] in spouse caregivers of persons with Alzheimer's disease (n = 82; mean age = 69.4) and noncaregiver spouses (n = 83) group matched on age and gender. Data were collected at study entry (T1) and 15-18 months later (T2). In men (n = 52), a depressed mood factor was negatively related to all mitogen responses at T1 and PHA at T2. Loneliness was the most important variable in the depressed mood factor. No relationships occurred in women (n = 113). At T2 an anger expression factor (anger-out--anger-control) was negatively related to all mitogen responses in caregivers. Anger-out was the most important variable for anger expression. Depressed mood at T1 predicted residualized changes in PHA at T2 in men. In conclusion, men with higher depressed mood and caregivers with higher anger expression may be at risk for lower proliferation responses.

Sense of coherence buffers relationships of chronic stress with fasting glucose levels

Sense of coherence (SOC) was examined as a buffer of the relationship of chronic stress with fasting glucose and insulin levels. Spouse caregivers of persons with diagnoses of Alzheimer's disease (AD) (n = 73) were compared to controls [spouses of nondemented persons (n = 69)], group-matched on age/gender. After controlling for anger and coronary heart disease (CHD), interactions of SOC and gender explained variance in glucose (but not insulin) at study entry (T1) and 15-18 months later (T2). However, this occurred only in caregivers. At both times SOC and glucose were negatively related in men caregivers but not in women caregivers or in controls. In caregivers (but not controls), SOC at T1 predicted glucose at T2, independent of gender, anger, and glucose at T1; and hassles at T1 appeared to mediate this relationship. Future research should examine SOC as a buffer of other chronic stressors and metabolic variables.

Korean American caregivers: who are they?

PURPOSE

To describe the caregiving role in the Korean American family.

DESIGN

Descriptive study.

METHOD

Thirty Korean American female caregivers were interviewed using a semistructured questionnaire related to sociodemographic background, caregiving history, filial responsibility, family network, cognitive status, dependency level, job-caregiving conflict, family conflict, economic strain, and negative life-style changes.

FINDINGS

The Korean American caregivers were elderly wives who were sharing households only with their elderly husbands, and these women were low-income, unemployed, less educated, and regarded their caregiving activity as a final assignment of obligation and duty given to them as spouse.

DISCUSSION

The Korean traditional cultural norm of filial piety plays a significant role for caregiving activities among Korean American caregivers.

IMPLICATION

Understanding cultural norms may enable health care providers to look below the surface even though caregivers may not express problems.

Relation between immune variables and burnout in a sample of physicians

OBJECTIVES

To evaluate in a group of physicians the relation between burnout, demographic or job characteristics, anxiety, and immune variables.

METHODS

Seventy one physicians of all grades were recruited among different departments to a cross sectional survey. The Maslach burnout inventory, scales of emotional exhaustion, depersonalisation, and personal accomplishment, the trait scale of anxiety inventory (STAI-Y2), and a questionnaire on personal and professional characteristics were administered. The immune profile included quantitative (number (%) of lymphocytes and subsets) and functional (natural killer cytotoxicity) measures.

RESULTS

With a model of stepwise multiple regression analysis, emotional exhaustion was significantly affected by both personal (marital, sex) and job characteristics (qualification, working activity), whereas only patient contact explained a portion of variation in depersonalisation. Furthermore, trait anxiety was found to predict the Maslach burnout inventory scores. After correction for potential confounders, physicians who scored high levels of personal accomplishment showed significantly higher numbers of total lymphocytes, T cells (CD3), T helper cells (CD4), and T suppressor cells (CD8) than those who scored low levels. No other correlation was found between burnout and immune variables.

CONCLUSIONS

In our group of relatively young physicians a high degree of personal accomplishment was associated with an increase in the number of peripheral lymphocytes, particularly T subsets. The meaning of this is not clear, although it could be speculated that to evaluate oneself positively, particularly with regard to work with patients in the health services, might help to stimulate the immune system. By contrast, there is no evidence that to work hard, to feel tired from work, and to have a cynical reaction towards patient care is related to immunosuppression.