Latent subgroups with distinct patterns of factors associated with self-rated successful aging among 1,510 community-dwelling Americans: potential role of wisdom as an implicit promoter

OBJECTIVES

To investigate whether latent subgroups with distinct patterns of factors associated with self-rated successful aging can be identified in community-dwelling adults, and how such patterns obtained from analysis of quantitative data are associated with lay perspectives on successful aging obtained from qualitative responses.

METHODS

Cross-sectional data were collected from 1,510 community-dwelling Americans aged 21-99 years. Latent class regression was used to identify subgroups that explained the associations of self-rated successful aging with measures of physical, cognitive, and mental health as well as psychological measures related to resilience and wisdom. Natural language processing was used to extract important themes from qualitative responses to open-ended questions, including the participants' definitions of successful aging.

RESULTS

Two latent subgroups were identified, and their main difference was that the wisdom scale was positively associated with self-rated successful aging in only one subgroup. This subgroup had significantly lower self-rated successful aging and worse scores for all health and psychological measures. In the subgroup's qualitative responses, the theme of wisdom was only mentioned by 10.6%; this proportion was not statistically different from the other subgroup, for which the wisdom scale was not statistically associated with the self-rated successful aging.

CONCLUSION

Our results showed heterogeneous patterns in the factors underpinning successful aging even in community-dwelling adults. We found the existence of a latent subgroup with lower self-rated successful aging as well as worse health and psychological scores, and we suggest a potential role of wisdom in promoting successful aging for this subgroup, even though individuals may not explicitly recognize wisdom as important for successful aging.

SOCIAL INTERACTIONS REDUCE ASSOCIATION BETWEEN LIFE-SPACE AND DAILY HAPPINESS IN OLDER ADULTS WITH AND WITHOUT HIV

Objective

We used global positioning system (GPS) derived indicators and ecological momentary assessment (EMA) to assess real-time relationships between life-space, mood, and social interactions among older adults with and without HIV.

Methods

Participants (People with HIV [PWH] n=54, HIV- n=34) completed smartphone-based EMA surveys assessing mood and social interactions four times/day for 14-days. Participants’ smartphones were GPS enabled. Mixed-effects models analyzed concurrent and lagged associations among life-space and mood.

Results

PWH spent more time at home (79% vs 70%, z=-2.08; p=.04) and reported lower mean happiness (3.2 vs 3.7; z=2.63; p=.007). More daily social interactions were associated with higher ratings of real-time happiness (b=0.12; t=5.61; p< 0.001). Prior day social interactions (b=0.15; t=7.3; p<.0001) and HIV status (b=-0.48; t=-2.56; df= 1026.8; p=0.01) diminished the effect of prior day time spent at home on happiness.

Conclusions

Interventions targeting social interaction may help increase positive mood in isolated older adults.

The interplay of daily affect and impulsivity measured by mobile surveys in bipolar disorder

Background

Impulsivity is a prominent feature of bipolar disorder associated with various negative sequelae; moreover, it may be a precursor to shifts in affect or mood, but little is known about its association with affect on a day-to-day timescale. Ecological momentary assessments (a method that captures moment-to-moment ratings of psychological states by repeatedly sampling the same individual) of impulsivity and affect using mobile surveys allow for more nuanced examination of mechanisms of mood and behavior dysregulation. However, few existing studies have validated an ecological momentary assessment of impulsivity in bipolar disorder and examined its time-lagged associations with positive and negative affect. 70 participants with bipolar disorder and 102 healthy comparisons participated in an intensive longitudinal study: they underwent 14 days of ecological momentary assessment data collection annually for 1–4 years. Multiple measures of impulsivity and affect were collected using self-report, behavioral, and ecological momentary assessment modalities; these measures were compared, and levels of impulsivity were compared between bipolar disorder and healthy comparison groups. Time-lagged analyses using daily means explored the next-day predictive relationship of impulsivity on positive/negative affect, and vice versa.

Results

The ecological momentary measure of impulsivity was moderately correlated with the self-report but not behavioral impulsivity measure. Bipolar disorder participants evinced higher self-report, behavioral, and daily impulsivity than healthy comparison participants. Time-lagged analyses revealed a bi-directional association between high impulsivity and high next-day negative (but not positive) affect. Post hoc analyses showed that impulsivity specifically predicted next-day anger and anxiety.

Conclusions

Our multimodal assessment of impulsivity allowed for an examination of the day-to-day course of impulsivity and affect, crucial steps toward understanding the mechanisms of mood symptom and episode onset in bipolar disorder.

A pilot randomised controlled trial to assess the feasibility and acceptability of recovery-focused therapy for older adults with bipolar disorder

BACKGROUND

Despite increasing evidence for the effectiveness of individual psychological interventions for bipolar disorder, research on older adults is lacking. We report the first randomised controlled trial of psychological therapy designed specifically for older adults with bipolar disorder.

AIMS

To evaluate the feasibility and acceptability of recovery-focused therapy, designed in collaboration with older people living with bipolar disorder.

METHOD

A parallel, two-armed, randomised controlled trial comparing treatment as usual with up to 14 sessions of recovery-focused therapy plus treatment as usual, for older adults with bipolar disorder.

RESULTS

Thirty-nine participants (67% female, mean age 67 years) were recruited over a 17-month period. Feasibility and acceptability of recruitment, retention (>80% observer-rated outcomes at both 24 and 48 weeks) and intervention processes were demonstrated. The majority of participants started therapy when offered, adhered to the intervention (68% attended all sessions and 89% attended six or more sessions) and reported positive benefits. Clinical assessment measures provide evidence of a signal for effectiveness on a range of outcomes including mood symptoms, time to relapse and functioning. No trial-related serious adverse events were identified.

CONCLUSIONS

Recovery-focused therapy is feasible, acceptable and has the potential to improve a range of outcomes for people living with bipolar disorder in later life. A large-scale trial is warranted to provide a reliable estimate of its clinical and cost-effectiveness.

Using mHealth to improve adherence and reduce blood pressure in individuals with hypertension and bipolar disorder (iTAB-CV): study protocol for a 2-stage randomized clinical trial

BACKGROUND

Cardiovascular disease in individuals with mental health conditions such as bipolar disorder is highly prevalent and often poorly managed. Individuals with bipolar disorder face significant medication adherence barriers, especially when they are prescribed multiple medications for other health conditions including hypertension. Poor adherence puts them at a disproportionate risk for poor health outcomes. As such, there is a need for effective interventions to improve hypertension medication adherence, particularly in patients that struggle with adherence due to mental health comorbidity.

METHODS

This 5-year project uses a 2-stage randomized controlled trial design to evaluate a brief, practical adherence intervention delivered via interactive text messaging (iTAB-CV) along with self-monitoring of medication taking, mood, and home blood pressure (N = 100) compared to self-monitoring alone (N = 100). Prior to randomization, all participants will view an educational video that emphasizes the importance of medication for the treatment of hypertension and bipolar disorder. Those randomized to the texting intervention will receive daily text messages with predetermined content to address 11 salient domains as well as targeted customized messages for 2 months. This group will then be re-randomized to receive either a high (gradual taper from daily to weekly texts) or low booster (weekly texts) phase for an additional 2 months. All participants will be monitored for 52 weeks. The primary outcomes are systolic blood pressure and adherence to antihypertensive medication as determined by a self-reported questionnaire and validated with an automated pill-monitoring device. Secondary outcomes include adherence to bipolar disorder medications, psychiatric symptoms, health status, self-efficacy for medication-taking behavior, illness beliefs, medication attitudes, and habit strength.

DISCUSSION

This study specifically targets blood pressure and mental health symptom control in people with bipolar and includes implementation elements in the study design intended to inform future scale-up. Promising pilot data and a theoretical model, which views sustained medication-taking behavior in the context of habit formation, suggests that this remotely delivered intervention may help advance care for this high-risk population and is amenable to both scale up and easy adaptation for other groups with poor medication adherence.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov ( NCT04675593 ) on December 19, 2020.

Automated Analysis of Drawing Process to Estimate Global Cognition in Older Adults: Preliminary International Validation on the US and Japan Data Sets

BACKGROUND

With the aging of populations worldwide, early detection of cognitive impairments has become a research and clinical priority, particularly to enable preventive intervention for dementia. Automated analysis of the drawing process has been studied as a promising means for lightweight, self-administered cognitive assessment. However, this approach has not been sufficiently tested for its applicability across populations.

OBJECTIVE

The aim of this study was to evaluate the applicability of automated analysis of the drawing process for estimating global cognition in community-dwelling older adults across populations in different nations.

METHODS

We collected drawing data with a digital tablet, along with Montreal Cognitive Assessment (MoCA) scores for assessment of global cognition, from 92 community-dwelling older adults in the United States and Japan. We automatically extracted 6 drawing features that characterize the drawing process in terms of the drawing speed, pauses between drawings, pen pressure, and pen inclinations. We then investigated the association between the drawing features and MoCA scores through correlation and machine learning-based regression analyses.

RESULTS

We found that, with low MoCA scores, there tended to be higher variability in the drawing speed, a higher pause:drawing duration ratio, and lower variability in the pen's horizontal inclination in both the US and Japan data sets. A machine learning model that used drawing features to estimate MoCA scores demonstrated its capability to generalize from the US dataset to the Japan dataset (R²=0.35; permutation test, P<.001).

CONCLUSIONS

This study presents initial empirical evidence of the capability of automated analysis of the drawing process as an estimator of global cognition that is applicable across populations. Our results suggest that such automated analysis may enable the development of a practical tool for international use in self-administered, automated cognitive assessment.

Evaluating the quality, safety, and functionality of commonly used smartphone apps for bipolar disorder mood and sleep self-management

Background

Individuals with bipolar disorder (BD) are increasingly turning to smartphone applications (apps) for health information and self-management support. While reviews have raised concerns regarding the effectiveness and safety of publicly available apps for BD, apps surveyed may not reflect what individuals with BD are using. The present study had two aims: first, to characterize the use of health apps to support mood and sleep amongst people with BD, and second, to evaluate the quality, safety and functionality of the most commonly used self-management apps.

Methods

A web-based survey was conducted to explore which apps people with BD reported using to support self-management of mood and sleep. The characteristics of the most commonly nominated apps were described using a standardized framework, including their privacy policy, clinical foundations, and functionality.

Results

Respondents (n = 919) were 77.9% female with a mean age of 36.9 years. 41.6% of participants (n = 382) reported using a self-management app to support mood or sleep. 110 unique apps were nominated in relation to mood, and 104 unique apps nominated in relation to sleep; however, most apps were only mentioned once. The nine most frequently nominated apps related to mood and sleep were subject to further evaluation. All reviewed apps offered a privacy policy, however user control over data was limited and the complexity of privacy policies was high. Only one app was developed for BD populations. Half of reviewed apps had published peer-reviewed evidence to support their claims of efficacy, but little research was specific to BD.

Conclusion

Findings illustrate the potential of smartphone apps to increase the reach of psychosocial interventions amongst people with BD. Apps were largely created by commercial developers and designed for the general population, highlighting a gap in the development and dissemination of evidence-informed apps for BD. There may be risks in using generic health apps for BD self-management; clinicians should enquire about patients’ app use to foster conversations about their particular benefits and limitations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00256-6.

Finding a Composite Measure for Data From Wrist Actigraphy in Bipolar Disorder

Actigraphy can objectively measure sleep in studies on Bipolar Disorder (BD) where subjective sleep ratings might be influenced by affect. Actigraphy data are complex necessitating data reduction approaches. We created a composite score of actigraphy sleep metrics (total sleep time [TST], wake after sleep onset [WASO], and percent sleep [PS]) in BD. We computed z-scores of sleep measures for n=51 BD vs. n=80 healthy subjects and averaged scores. We examined associations with participant characteristics and used LASSO to identify metrics best explaining composite variability. Higher composite scores (better sleep) were seen in employed vs. unemployed (t=2.40, df=34, p=0.02), and correlated with higher medication load (r=0.41, p=0.004), lower mania symptomatology (r=-0.33, p=0.04) and lower interleukin (IL)-6 levels (r=-0.32, p=0.02). TST best explained variability in medication load and PS best explained employment, mania symptoms and IL-6. Given observed specificity of associations, selecting theory-driven sleep metrics may be more appropriate than a composite.

Assessing Physical Rehabilitation Exercises using Graph Convolutional Network with Self-supervised regularization

Computer-vision techniques provide a way to conduct low-cost, portable, and real-time evaluations of exercises performed as a part of physical rehabilitation. Recent data-driven methods have explored using deep learning on 3D body-landmark sequences for automatic assessment of physical rehabilitation exercises. However, existing deep learning methods using convolutional neural networks (CNN) fail to utilize the spatial connection information of the human body, which limits the accuracy of these assessments. To overcome these limitations and provide a more accurate method to assess physical rehabilitation exercises, we propose a deep learning framework using a graph convolutional network (GCN) with self-supervised regularization. The experimental results on an existing benchmark dataset validate that the proposed method achieves state-of-the-art performance with lower error than other CNN methods, and the self-supervised learning improves the prediction accuracy.Clinical relevance-This work established a supervised learning method to automatically assess physical rehabilitation exercises in the home environment using computer vision. This low-cost, portable, and real-time evaluation may provide clinicians with a way to provide feedback to patients about their exercise performance without having to provide in-person supervision.

Utilizing the couple relationship to prevent suicide: A preliminary examination of Treatment for Relationships and Safety Together

OBJECTIVE

To evaluate the feasibility, preliminary effects, and acceptability of the first comprehensive couple-based treatment for suicide, called Treatment for Relationships and Safety Together (TR&ST).

METHOD

In a preliminary examination, five couples (N = 10) participated in 10 weekly sessions of TR&ST. All couples included a veteran who reported active suicidal ideation at baseline and their partner. Couples completed measures of relationship functioning, perceived burdensomeness, thwarted belonging, and suicidal ideation at baseline, mid-treatment, and posttreatment.

RESULTS

TR&ST was feasible to deliver. Veteran and partner relationship functioning improved and veteran perceived burdensomeness, thwarted belonging, and suicidal ideation decreased. There were no suicide related behaviors, hospitalizations, or crisis line calls during the study. TR&ST seemed acceptable to couples (100% retention and high satisfaction ratings).

CONCLUSION

Couple-based suicide prevention may provide an additional avenue for suicide prevention in veterans.

Implementing eScreening for suicide prevention in VA post-9/11 transition programs using a stepped-wedge, mixed-method, hybrid type-II implementation trial: a study protocol

BACKGROUND

Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment, thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve the rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening.

METHODS

This is an eight-site 4-year, stepped-wedge, mixed-method, hybrid type-II implementation trial comparing eScreening to screening as usual while also evaluating the potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper-based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high- and low-eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews.

DISCUSSION

The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real-world clinical care programs.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT04506164; date registered: August 20, 2020; retrospectively registered.

Health Impacts of the Stay-at-Home Order on Community-Dwelling Older Adults and How Technologies May Help: Focus Group Study

BACKGROUND

As of March 2021, in the USA, the COVID-19 pandemic has resulted in over 500,000 deaths, with a majority being people over 65 years of age. Since the start of the pandemic in March 2020, preventive measures, including lockdowns, social isolation, quarantine, and social distancing, have been implemented to reduce viral spread. These measures, while effective for risk prevention, may contribute to increased social isolation and loneliness among older adults and negatively impact their mental and physical health.

OBJECTIVE

This study aimed to assess the impact of the COVID-19 pandemic and the resulting "Stay-at-Home" order on the mental and physical health of older adults and to explore ways to safely increase social connectedness among them.

METHODS

This qualitative study involved older adults living in a Continued Care Senior Housing Community (CCSHC) in southern California, USA. Four 90-minute focus groups were convened using the Zoom Video Communications platform during May 2020, involving 21 CCSHC residents. Participants were asked to describe how they were managing during the "stay-at-home" mandate that was implemented in March 2020, including its impact on their physical and mental health. Transcripts of each focus group were analyzed using qualitative methods.

RESULTS

Four themes emerged from the qualitative data: (1) impact of the quarantine on health and well-being, (2) communication innovation and technology use, (3) effective ways of coping with the quarantine, and (4) improving access to technology and training. Participants reported a threat to their mental and physical health directly tied to the quarantine and exacerbated by social isolation and decreased physical activity. Technology was identified as a lifeline for many who are socially isolated from their friends and family.

CONCLUSIONS

Our study findings suggest that technology access, connectivity, and literacy are potential game-changers to supporting the mental and physical health of older adults and must be prioritized for future research.

A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial

BACKGROUND

People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions.

OBJECTIVE

The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention.

METHODS

A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement.

RESULTS

The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models.

CONCLUSIONS

The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14378.

Links between objective sleep and sleep variability measures and inflammatory markers in adults with bipolar disorder

Premature mortality and increased physical comorbidity associated with bipolar disorder (BD) may be related to accelerated biological aging. Sleep disturbances and inflammation may be key mechanisms underlying accelerated aging in adults with BD. To our knowledge, these relationships have not been examined rigorously. This cross-sectional study included 50 adults with BD and 73 age- and sex-comparable non-psychiatric comparison (NC) subjects, age 26-65 years. Participants were assessed with wrist-worn actigraphy for total sleep time (TST), percent sleep (PS), and bed/wake times for 7 consecutive nights as well as completing scales for subjective sleep quality. Within-individual variability in sleep measures included intra-individual standard deviation (iSD) and atypicality of one evening's sleep. Blood-based inflammatory biomarkers included interleukin (IL)-6, C-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-α). Linear regression analyses tested relationships of mean and iSD sleep variables with inflammatory marker levels; time-lagged analyses tested the influence of the previous evening's sleep on inflammation. BD participants had worse subjective sleep quality, as well as greater TST iSD and wake time iSD compared to the NC group. In all participants, higher TST iSD and lower mean PS were associated with higher IL-6 levels (p = 0.04, η_p² = 0.042; p = 0.05, η_p² = 0.039, respectively). Lower mean PS was associated with higher CRP levels (p = 0.05, η_p² = 0.039). Atypicality of the previous night's TST predicted next day IL-6 levels (p = 0.05, η_p² = 0.04). All of these relationships were present in both BD and NC groups and remained significant even after controlling for sleep medications. Overall, sleep measures and their variability may influence inflammatory markers in all adults. Thus, sleep may be linked to the inflammatory processes believed to underlie accelerated aging in BD.

Mobile-Assisted Cognitive Behavioral Therapy for Negative Symptoms: Open Single-Arm Trial With Schizophrenia Patients

BACKGROUND

Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn).

OBJECTIVE

The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia.

METHODS

Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms.

RESULTS

Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes.

CONCLUSIONS

The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696.

A Virtual Reality Intervention for the Treatment of Phantom Limb Pain: Development and Feasibility Results

OBJECTIVE

To describe the development of a virtual reality (VR) treatment for phantom limb pain (PLP) and phantom sensations and provide feasibility data from testing the treatment in a population of veterans.

DESIGN & SUBJECTS

Fourteen participants completed a baseline visit evaluating their amputation, PLP, and phantom sensations. Subsequently, participants completed a VR treatment modeled after mirror therapy for PLP, navigating in a VR environment with a bicycle pedaler and motion sensor to pair their cadence to a VR avatar. The VR avatar enabled visualization of the participant's intact phantom limb in motion, a hypothesized mechanism of mirror therapy.

SETTING

Laboratory.

METHODS

Participants completed pre- and post-treatment measures to evaluate changes in PLP, phantom sensations, and rate helpfulness, realism, immersion, adverse experiences, and treatment satisfaction.

RESULTS

Eight of 14 participants (57.1%) reported PLP pre-VR treatment, and 93% (13/14) reported one or more unpleasant phantom sensations. After treatment, 28.6% (4/14) continued to report PLP symptoms (t[13] = 2.7, P = 0.02, d = 0.53) and 28.6% (4/14) reported phantom sensations (t[13] = 4.4, P = 0.001, d = 1.7). Ratings of helpfulness, realism, immersion, and satisfaction were uniformly high to very high. There were no adverse experiences. Four participants completed multiple VR treatments, showing stable improvements in PLP intensity and phantom sensations and high user ratings.

CONCLUSIONS

This feasibility study of a novel VR intervention for PLP was practical and was associated with significant reductions in PLP intensity and phantom sensations. Our findings support continued research in VR-based treatments in PLP, with a need for direct comparisons between VR and more established PLP treatments.

Moment-to-Moment Associations Between Depressive Symptoms and Daily Functioning Among Stroke Survivors: An Ecological Momentary Assessment (EMA) Study

Date Presented 03/27/20

This study used smartphone-based EMA to investigate moment-to-moment associations between poststroke depressive symptoms and daily functioning. We found that fatigue and lack of interest can be target symptoms to improve daily functioning among stroke survivors. Improving self-appraisals of daily functioning can be an effective way to manage depressive symptoms. EMA can be a useful tool to track real-time target symptoms in naturalistic contexts.

Primary Author and Speaker: Yejin Lee

Additional Authors and Speakers: Eric Lenze, Carolyn Baum, Jin-Moo Lee, Christopher Metts, Michael Yingling, Robert Fucetola, Mandy Fong, Colin Depp, Robert Heaton, Chenyang Lu, Albert Lai

Contributing Authors: Alex Wong

Home-Based Cognitively Assistive Robots: Maximizing Cognitive Functioning and Maintaining Independence in Older Adults Without Dementia

Promoting health and prolonging independence in the home is a priority for older adults, caregivers, clinicians, and society at large. Rapidly developing robotics technology provides a platform for interventions, with the fields of physically and socially assistive robots expanding in recent years. However, less attention has been paid to using robots to enhance the cognitive health of older adults. The goal of this review is to synthesize the current literature on home-based cognitively assistive robots (CAR) in older adults without dementia and to provide suggestions to improve the quality of the scientific evidence in this subfield. First, we set the stage for CAR by: a) introducing the field of robotics to improve health, b) summarizing evidence emphasizing the importance of home-based interventions for older adults, c) reviewing literature on robot acceptability in older adults, d) highlighting important ethical issues in healthcare robotics, and e) reviewing current findings on socially assistive robots, with a focus on translating findings to the CAR context. With this foundation in place, we then review the literature on CAR, identifying gaps and limitations of current evidence, and proposing future directions for research. We conclude that CAR is promising and feasible and that there is a need for more methodologically rigorous evaluations of CAR to promote prolonged home-based independence in older adults.

Mindfulness, Education, and Exercise for age-related cognitive decline: Study protocol, pilot study results, and description of the baseline sample

BACKGROUND/AIMS

Age-related cognitive decline is a pervasive problem in our aging population. To date, no pharmacological treatments to halt or reverse cognitive decline are available. Behavioral interventions, such as physical exercise and Mindfulness-Based Stress Reduction, may reduce or reverse cognitive decline, but rigorously designed randomized controlled trials are needed to test the efficacy of such interventions.

METHODS

Here, we describe the design of the Mindfulness, Education, and Exercise study, an 18-month randomized controlled trial that will assess the effect of two interventions-mindfulness training plus moderate-to-vigorous intensity exercise or moderate-to-vigorous intensity exercise alone-compared with a health education control group on cognitive function in older adults. An extensive battery of biobehavioral assessments will be used to understand the mechanisms of cognitive remediation, by using structural and resting state functional magnetic resonance imaging, insulin sensitivity, inflammation, and metabolic and behavioral assessments.

RESULTS

We provide the results from a preliminary study (n = 29) of non-randomized pilot participants who received both the exercise and Mindfulness-Based Stress Reduction interventions. We also provide details on the recruitment and baseline characteristics of the randomized controlled trial sample (n = 585).

CONCLUSION

When complete, the Mindfulness, Education, and Exercise study will inform the research community on the efficacy of these widely available interventions improve cognitive functioning in older adults.

A Web-Based Adaptation of the Quality of Life in Bipolar Disorder Questionnaire: Psychometric Evaluation Study

BACKGROUND

Quality of life (QoL) is considered a key treatment outcome in bipolar disorder (BD) across research, clinical, and self-management contexts. Web-based assessment of patient-reported outcomes offer numerous pragmatic benefits but require validation to ensure measurement equivalency. A web-based version of the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire was developed (QoL Tool).

OBJECTIVE

This study aimed to evaluate the psychometric properties of a web-based QoL self-report questionnaire for BD (QoL Tool). Key aims were to (1) characterize the QoL of the sample using the QoL Tool, (2) evaluate the internal consistency of the web-based measure, and (3) determine whether the factor structure of the original version of the QoL.BD instrument was replicated in the web-based instrument.

METHODS

Community-based participatory research methods were used to inform the development of a web-based adaptation of the QoL.BD instrument. Individuals with BD who registered for an account with the QoL Tool were able to opt in to sharing their data for research purposes. The distribution of scores and internal consistency estimates, as indicated by Cronbach alpha, were inspected. An exploratory factor analysis using maximum likelihood and oblique rotation was conducted. Inspection of the scree plot, eigenvalues, and minimum average partial correlation were used to determine the optimal factor structure to extract.

RESULTS

A total of 498 people with BD (349/498, 70.1% female; mean age 39.64, SD 12.54 years; 181/498, 36.3% BD type I; 195/498, 39.2% BD type II) consented to sharing their QoL Tool data for the present study. Mean scores across the 14 QoL Tool domains were, in general, significantly lower than that of the original QoL.BD validation sample. Reliability estimates for QoL Tool domains were comparable with that observed for the QoL.BD instrument (Cronbach alpha=.70-.93). Exploratory factor analysis supported the extraction of an 11-factor model, with item loadings consistent with the factor structure suggested by the original study. Findings for the sleep and physical domains differed from the original study, with this analysis suggesting one shared latent construct.

CONCLUSIONS

The psychometric properties of the web-based QoL Tool are largely concordant with the original pen-and-paper QoL.BD, although some minor differences in the structure of the sleep and physical domains were observed. Despite this small variation from the factor structure identified in the QoL.BD instrument, the latent factor structure of the QoL Tool largely reproduced the original findings and theoretical structure of QoL areas relevant to people with BD. These findings underscore the research and clinical utility of this instrument, but further comparison of the psychometric properties of the QoL Tool relative to the QoL.BD instrument is warranted. Future adaptations of the QoL Tool, including the production of an app-based version of the QoL Tool, are also discussed.

Suicidal ideation, behavior, and mortality in male and female US veterans with severe mental illness

BACKGROUND

We compared male and female American veterans with schizophrenia or bipolar disorder regarding clinical characteristics associated with lifetime suicidal ideation and behavior. Subsequent mortality, including death by suicide, was also assessed.

METHODS

Data from questionnaires and face-to-face evaluations were collected during 2011-2014 from 8,049 male and 1,290 female veterans with schizophrenia or bipolar disorder. In addition to comparing male-female characteristics, Cox regression models-adjusted for demographic information, medical-psychiatric comorbidities, and self-reported suicidal ideation and behavior-were used to examine gender differences in associations of putative risk factors with suicide-specific and all-cause mortality during up to six years of follow-up.

RESULTS

Women overall were younger, more likely to report a history of suicidal behavior, less likely to be substance abusers, and had lower overall mortality during follow-up. Among women only, psychiatric comorbidity was paradoxically associated with lower all-cause mortality (hazard ratio [HR]=0.53, 95% CI, 0.29-0.96, p = 0.037 for 1 disorder vs. none; HR=0.44, 95% CI, 0.25-0.77, p = 0.004 for ≥2 disorders vs. none). Suicide-specific mortality involved relatively few events, but crude rates were an order of magnitude higher than in the U.S. general and overall veteran populations.

LIMITATIONS

Incomplete cause-of-death information and low statistical power for male-female comparisons regarding mortality.

CONCLUSIONS

Female veterans with SMI differed from females in the general population by having a higher risk of suicide attempts. They also had more lifetime suicide attempts than male veterans with same diagnoses. These differences should inform public policy and clinical planning.

Differential Medication Attitudes to Antihypertensive and Mood Stabilizing Agents in response to an Automated Text-Messaging Adherence Enhancement Intervention

OBJECTIVES

Individuals with serious mental illnesses such as bipolar disorder (BD) are at an increased risk for poor medication adherence compared to the general population. Individuals with BD also have high rates of chronic comorbid medical conditions like hypertension (HTN), diabetes, and cardiovascular disease. Cognitive-behavioral therapies often integrate strategies to improve medication adherence by targeting medication attitudes and self-efficacy, but the pathway toward behavior change needs further investigation.

METHODS

This 3-month prospective, single-arm cohort study tested an automated SMS intervention entitled Individualized Texting for Adherence Building- Cardiovascular (iTAB-CV) in 38 participants with BD and HTN. The Tablets Routine Questionnaire (TRQ) measures the percentage of BD and HTN non-adherence over the past week and the past month. Attitudinal and habit measures including the Brief Illness Perception Questionnaire (Brief IPQ), the Medication Adherence Self-Efficacy Scale-Revised (MASES-R), the Self-Report Habit Index (SRHI), the Beliefs about Medicines Questionnaire (BMQ), and the Attitudes toward Mood Stabilizers Questionnaire (AMSQ) were given for BD and HTN medications. Correlational analyses were run to determine the associations between BD and HTN attitudinal and habit indices. Additionally, longitudinal analyses were conducted to determine if attitudes changed over time as a function of a 2-month mobile-health intervention.

RESULTS

Illness attitudes towards BD were worse than towards HTN at the start of the study. Attitudes toward BD and towards mood-stabilizing drugs as well as antihypertensives improved following a mHealth intervention aimed at improving adherence. Furthermore, self-efficacy and habit strength for both BD and HTN drugs were correlated and were responsive to the intervention, with most of the change occurring after the first month of the intervention and not requiring the addition of the explicit reminders.

CONCLUSION

Participants who received iTAB-CV showed improved attitudes towards BD and mood-stabilizing medication, and had an improvement in self-efficacy and habit strength towards taking both BD and HTN medications. Increased attention to mechanisms of change in mHealth interventions for adherence may facilitate impact. It should be noted that the methodology of the study limits drawing causal conclusions and suggests the need for a randomized control trial.

What Do People With Schizophrenia Do All Day? Ecological Momentary Assessment of Real-World Functioning in Schizophrenia

Schizophrenia is a major cause of disability worldwide. As new treatments for functioning are tested, the need grows to demonstrate real-world functioning gains. Ecological momentary assessment (EMA) may provide a more ecologically valid measure of functioning. In this study, smartphone-based EMA was used to signal participants with schizophrenia (N = 100) and controls (N = 71) 7 times a day for 7 days to respond to brief questionnaires about social interactions and functioning behaviors. Excellent adherence was found, with both groups completing an average of 85% of surveys and only 3% of participants with schizophrenia excluded for poor adherence. Four-week test-retest reliability was high (r = .83 for total productive behaviors). Relative to controls, participants with schizophrenia reported significantly less total productive activity (d = 1.2), fewer social interactions (d = 0.3), more nonproductive behaviors (d = 1.0; watching TV, resting), and more time at home (d = 0.8). Within the schizophrenia group, participants living independently showed better functioning on EMA relative to participants in supported housing (d = 0.8) and participants engaged in vocational activities showed better functioning than individuals not engaged in vocational activities (d = 0.55). Modest correlations were found between EMA and an in-lab self-report measure of functioning activities performed in the community, but not between EMA and measures of functional capacity or potential. This study demonstrated the feasibility, sensitivity reliability, and validity of EMA methods to assess functioning in schizophrenia. EMA provides a much-needed measure of what individuals with schizophrenia are actually doing in real-world contexts. These results also suggest that there may be important disjunctions between indices of abilities and actual real-world functioning.

Electronic Ecological Momentary Assessment (EMA) in youth with bipolar disorder: Demographic and clinical predictors of electronic EMA adherence

BACKGROUND

Ecological momentary assessment (EMA) is increasingly used to characterize patients' daily lives, monitor mood, and test efficacy of treatment interventions. However, few studies have examined patient characteristics impacting adherence with EMA protocols, and to our knowledge, no such study has been conducted in youth with bipolar disorder (BD).

METHODS

As part of a larger observational study, 14- to 21-year-olds diagnosed with BD, and who were between episodes of illness (n = 39, 19.0 ± 2.05 Mean ± Standard Deviation years old, 74.4% female) and psychiatrically healthy controls (n = 47, 18.3 ± 2.40 years old, 66.0% female) completed baseline diagnostic and symptom severity interviews, and were instructed to complete diary assessments of mood, sleep, and behavior electronically three times per day for 21 consecutive days (i.e., in total 5418 (or 63 per person) diary entries). Multiple regression was used to examine effects of BD participants' demographic and clinical characteristics on diary completion rates.

RESULTS

53.8 ± 9.3 diary entries per person were actually completed. Adherence rates were high (87.5% of healthy controls and 80.4% of adolescents with BD), but were still significantly poorer in youth with BD. Adequate adherence (≥80%) rates were also significantly poorer in youth with BD relative to healthy controls (56.4% versus 83.0%). Among youth with BD, more lifetime suicide attempts and higher current mood elevation symptom severity predicted significantly poorer adherence.

LIMITATIONS

Limited sample size/generalizability.

CONCLUSIONS

Findings highlight the importance of considering the impact of patient characteristics on adherence with EMA protocols among youth with severe mental illness.

Study of Independent Living Residents of a Continuing Care Senior Housing Community: Sociodemographic and Clinical Associations of Cognitive, Physical, and Mental Health

OBJECTIVE

To examine associations of sociodemographic and clinical factors with cognitive, physical, and mental health among independent living older adults in a continuing care senior housing community (CCSHC).

METHODS

This was a cross-sectional study at the independent living sector of a CCSHC in San Diego County, California. Participants included English-speaking adults aged 65-95 years, of which two-thirds were women. Of the 112 subjects recruited, 104 completed basic study assessments. The authors computed composite measures of cognitive, physical, and mental health. The authors also assessed relevant clinical correlates including psychosocial factors such as resilience, loneliness, wisdom, and social support.

RESULTS

The CCSHC residents were similar to a randomly selected community-based sample of older adults on most standardized clinical measures. In the CCSHC, physical health correlated with both cognitive function and mental health, but there was no significant correlation between cognitive and mental health. Cognitive function was significantly associated with physical mobility, satisfaction with life, and wisdom, whereas physical health was associated with age, self-rated physical functioning, mental well-being, and resilience. Mental health was significantly associated with income, optimism, self-compassion, loneliness, and sleep disturbances.

CONCLUSION

Different psychosocial factors are significantly associated with cognitive, physical, and mental health. Longitudinal studies of diverse samples of older adults are necessary to determine risk factors and protective factors for specific domains of health. With rapidly growing numbers of older adults who require healthcare as well as supportive housing, CCSHCs will become increasingly important sites for studying and promoting the health of older adults.

B-38 Gamified Mobile Cognitive Tests: Preliminary Feasibility and Acceptability in Persons with Bipolar Disorder

Objective

Current measurements of cognitive functioning are time-consuming and costly, often done as point-in-time assessments. We examined the feasibility and acceptability of six newly developed smartphone-based mobile cognitive tests (MCTs), completed in the real-world, among persons with bipolar disorder (BD) and healthy controls (HC).

Methods

Thirteen community-dwelling participants (seven BD and six HC), aged 18-65, completed in-person neurobehavioral assessments at baseline and our MCTs three times daily for the following 14 days. The MCTs measure cognition in the following domains: reaction time, executive functions, attention, processing speed, working memory, and learning and memory. Our protocol delivered 1-2 MCTs per session, and each test was only administered once daily. Timing of the MCTs was adjusted according to individual sleep/wake schedules.

Results

MCT adherence was, on average, high (82.38%). The two groups did not differ in terms of adherence (p = 0.45, 95% CI = -29.51, 13.96) or average completion time (5.21 mins, SD = 1.54 min per each assessment period; t(11) = 1.12, p = .29, 95% CI = -0.91, 2.81). There was no relationship between age and adherence (r = .296, p = .326). Acceptability was measured at follow-up via a Likert-scale rating from 0 = not at all to 4 = very much; mean likeability was high (M = 3.0, SD = 1.28). Most participants noted a high willingness to complete additional MCT testing in the future.

Conclusion

Our preliminary findings indicate mobile cognitive testing is feasible and accepted among bipolar disorder and comparison participants. The implications of using smartphone-based MCTs are far reaching, including increased visibility of cognitive changes over time as well as examining real-time temporal relationships between cognition and other lifestyle and environmental factors.

A-54 Greater Time Spent Watching TV is Related to Worse Real-Time Neurocognitive Performance in Older Adults With and Without HIV

Objective

There is a need to identify determinants of neurocognitive impairment among older persons living with HIV (PLHIV). Utilizing smartphone-based Ecological Momentary Assessment (EMA) and mobile cognitive testing, we examined the relationships between daily life activities and real-world neurocognitive performance among older PLHIV and HIV-uninfected adults.

Method

Ninety-one participants (58 PLHIV; Mage = 59.4, SD = 6.4), 70.3% male, 65.9% non-Hispanic white, completed four smartphone-based EMA surveys of daily activities and one mobile color-word interference test (mCWIT) per day for 14 days. Daily activities were grouped into five categories: activities of daily living (ADLs, IADLs), cognitively demanding activities, socially-engaging activities, physical activity (PA), and passive leisure activity (watching TV). Data was collapsed across the 14 days to examine between-person effects of the proportion of time reportedly spent on each activity on neurocognitive outcomes (the average correct responses and completion time for the mCWIT).

Results

No effect was found for engaging in activities by HIV status; however, PLHIV had significantly longer times on the mCWIT compared to persons without HIV (t = 2.49; 95% CI: 0.60, 5.37; p = 0.02). In a multivariable regression model accounting for HIV status, a greater proportion of time spent watching TV was associated with slower average mCWIT performance (beta = 9.41; 95% CI: 1.88,17.0; p = 0.01). There were no relationships between other domains of daily life activities and mCWIT performance.

Conclusion

Our findings provide evidence that more time spent watching TV is associated with slower mCWIT performance. Future work examining the time-lagged relationships between these variables is needed to understand whether watching TV decreases real-time neurocognitive performance.

Outcomes of Psychoeducation and a Text Messaging Adherence Intervention Among Individuals With Hypertension and Bipolar Disorder

OBJECTIVE

This study evaluated the feasibility, acceptability, and preliminary efficacy of psychoeducation plus an automated text messaging intervention (Individualized Texting for Adherence Building-Cardiovascular [iTAB-CV]) to improve adherence to antihypertensives and bipolar disorder medication.

METHODS

After a psychoeducation program, iTAB-CV was administered for 2 months. In month 1, participants received one educational-motivational and one mood rating text daily. In month 2, medication reminders were added.

RESULTS

The sample (N=38) was 74% African American and 53% women, with a mean±SD age of 51.53±9.06. Antihypertensive nonadherence decreased from a mean of 43%±23% to 21%±18% at 12 weeks (χ²=34.6, df=3, p<0.001). Systolic blood pressure decreased from a mean of 144.8±15.5 mmHg to 136.0±17.8 mmHg (χ²=17.6, df=3, p<.001). Retention was 100%.

CONCLUSIONS

In this uncontrolled trial, participants were highly engaged and medication adherence and reduced systolic blood pressure were sustained after psychoeducation plus iTAB-CV. Because iTAB-CV is automated and delivered remotely, it has the potential to reach a large and challenging population.

Impact of time perspectives on texting intervention to reduce HIV/STI transmission among female sex workers in Tijuana and Ciudad Juarez, Mexico

Text messages may sustain post-counseling gains in behavioral improvements and reduce HIV/STI incidence. However, their effectiveness may depend on the messages' time perspective and characteristics of the individual. We evaluated the impact of time perspective on a text messaging intervention designed to maintain improvements in safer sex practices among drug-using and non-drug-using female sex workers (FSWs) in Tijuana (n = 141) and Cd. Juarez (n = 129), Mexico. FSWs received the efficacious Mujer Segura intervention, and were randomized to receive safer sex maintenance text messages with either a short-term or future-oriented time perspective. The outcome was HIV/STI incidence rate over 6-month follow-up. In Tijuana, combined HIV/STI incidence density was lower among FSWs in the FUTURE group (31.67 per 100 py) compared to women in the SHORT-TERM group (62.40 per 100 py). Conversely, in Cd. Juarez, HIV/STI incidence density was lower (although non-significant) among FSWs in the SHORT-TERM group (19.80 per 100 py) compared to those in the FUTURE group (35.05 per 100 py). These findings suggest that future-oriented text messages may sustain post-counseling improvements in sexual risk behavior among FSWs, but findings may vary by FSWs' characteristics (e.g., drug use), and by region and context.

Psychosocial Correlates of Frailty Among HIV-Infected and HIV-Uninfected Adults

Frailty is a geriatric condition characterized by increased vulnerability to physical impairments and limitations that may lead to disabilities and mortality. Although studies in the general population suggest that psychosocial factors affect frailty, less is known about whether similar associations exist among people living with HIV (PLWH). The purpose of this study was to examine psychosocial correlates of frailty among PLWH and HIV-uninfected adults. Our sample included 127 adults (51% PLWH) participating in the Multi-Dimensional Successful Aging among HIV-Infected Adults study at the University of California San Diego (average age 51 years, 80% male, 53% White). Frailty was assessed via the Fried Frailty Index. Psychosocial variables significant in bivariate models were included in principal component analysis to generate factor variables summarizing psychosocial correlates. Multivariate logistic regression models were fit to examine the independent effects of factor variables and their interaction terms with HIV status. In bivariate models, frailty was associated with multiple psychosocial variables, for example, grit, optimism, personal mastery, social support, emotional support. Factor analysis revealed that psychosocial variables loaded on two factors-Positive Resources/Outlook and Support by Others. The multivariate model showed significant main effects of Support by Others and HIV status, and interactive effects HIV X Positive Resources/Outlook, such that Positive Resources/Outlook was negatively associated with frailty for PLWH but not for HIV-uninfected individuals. These analyses indicate that psychosocial factors may be associated with frailty among PLWH. Positive resources and outlook may play a role in frailty prevention. Future longitudinal studies are needed to establish causal links.

Cognitive and functional deficits in bipolar disorder and schizophrenia as a function of the presence and history of psychosis

OBJECTIVES

Schizophrenia and bipolar disorder overlap considerably. Schizophrenia is a primary psychotic disorder, whereas approximately half of people with bipolar disorder will experience psychosis. In this study, we examined the extent to which cognitive and functional impairments are related to the presence and history of psychosis across the two disorders.

METHOD

A total of 633 participants with bipolar disorder I, schizophrenia, and schizoaffective disorder were recruited for a study on the genetics of cognition and functioning in bipolar disorder and schizophrenia. Participants were classified into five groups: bipolar disorder with current psychosis (N = 30), bipolar disorder with a history of psychosis (N = 162), bipolar disorder with no history of psychosis (N = 92), schizophrenia with current psychosis (N = 245), and schizophrenia with past psychosis (N = 104).

RESULTS

Cognitive profiles of all groups were similar in pattern; however, both current psychosis (P < .02) and a diagnosis of schizophrenia (P < .03) were associated with greater impairment. Schizophrenia with current psychosis was also associated with a superimposed severe impairment in processing speed. Both psychosis (P < .03) and schizophrenia diagnosis (P < .01) were associated with poorer functional competence. Individuals with bipolar disorder and schizophrenia experienced similar impairments in real-world functioning if they were experiencing current psychosis (P = .32).

CONCLUSION

The presence of active psychosis is an important cross-diagnostic factor in cognition and functioning in both schizophrenia and bipolar disorder. Characterization and treatment of cognition and functional deficits in bipolar disorder should consider the effects of both current and history of psychosis.

Smartphones, Sensors, and Machine Learning to Advance Real-Time Prediction and Interventions for Suicide Prevention: a Review of Current Progress and Next Steps

PURPOSE OF REVIEW

As rates of suicide continue to rise, there is urgent need for innovative approaches to better understand, predict, and care for those at high risk of suicide. Numerous mobile and sensor technology solutions have already been proposed, are in development, or are already available today. This review seeks to assess their clinical evidence and help the reader understand the current state of the field.

RECENT FINDINGS

Advances in smartphone sensing, machine learning methods, and mobile apps directed towards reducing suicide offer promising evidence; however, most of these innovative approaches are still nascent. Further replication and validation of preliminary results is needed. Whereas numerous promising mobile and sensor technology based solutions for real time understanding, predicting, and caring for those at highest risk of suicide are being studied today, their clinical utility remains largely unproven. However, given both the rapid pace and vast scale of current research efforts, we expect clinicians will soon see useful and impactful digital tools for this space within the next 2 to 5 years.

IS BEING A PREMATURE OR HAVING ABNORMAL BIRTH WEIGHT ASSOCIATED WITH DEPRESSION AMONG 6 - 17 YEARS OLD U.S. CHILDREN?

BACKGROUND

Reports in 2015 showed that premature birth rate in the United States increased when compared to 2014 data, and this was the first increment since 2007. Major complications of prematurity and birth weight abnormalities are well known, but other complications including mental health abnormalities require more investigation to understand their association well.

OBJECTIVES

We aimed in this study to determine if prematurity and birth weight abnormalities including very low birth weight (VLBW) and low birth weight (LBW) are associated with depression among United States children aged between six and seventeen years old.

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DESIGN/METHODS

This is a cross sectional study using data from the National Survey of Children’s Health (NSCH) 2011–2012. When we applied our selection criteria, 84,182 children out of the total 95,677 NSCH population were selected. Our exclusion criteria were: age less than six years, child’s history of cerebral palsy, and mental retardation. Multivariable logistic regression was done to control for confounding effects when studying the association of prematurity, birth weight abnormalities and depression.

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RESULTS

Our results reveal that 3.6% of our population had history of depression, 11% were born prematurely, 7.4% had low birth weight, and 1.5% had very low birth weight. Depression was more frequent in children who were born prematurely (prevalence 4.3%) when compared to children born at term. Different models were built to analyze the association between prematurity, birth weight abnormalities and depression. There was no detectable statistically significant association when controlling for demographic data (age, gender, race, family structure) and mental health risk factors (parental poor mental health, chronic health conditions) as well as other factors. Results reveal that children who had chronic health conditions or had adverse family experiences have greater odds of having depression. On the other hand, African-American, male, and younger (6–11 years old) children have lower odds of depression.

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CONCLUSION

Further longitudinal studies are required to establish a causal relationship of behavioral and psychological complications, and to determine the biological mechanisms of brain development that could be associated with depression among premature infants or those who have birth weight abnormalities.

Patient Participation in the Development of a Customized M-Health Intervention to Improve Medication Adherence in Poorly Adherent Individuals with Bipolar Disorder (BD) and Hypertension (HTN)

Objective

Individuals living with bipolar disorder (BD) have poorer management of chronic medical conditions such as hypertension (HTN), and worse treatment adherence than the general population. The study objective was to obtain information from patients with both BD and HTN that would inform the development of an m-Health intervention to improve medication adherence for poorly adherent individuals living with both these chronic illnesses.

Methods

Focus group methodology was used to collect information from 13 participants on perceived barriers and facilitators to BD and HTN medication adherence, as well as feedback on the demonstration and use of a bidirectional text messaging system for medication reminders. Focus groups were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes.

Results

Forgetfulness was the most frequently mentioned barrier to taking antihypertensive medications, and decisions about taking them were often influenced by BD mood fluctuations and the burden of having to take "too many pills" for both chronic illnesses. Participants' feedback about the use of a text-messaging system to help with medication adherence for BD and HTN was very positive, and their suggestions for modification were incorporated into a more customized system for testing in a Phase 2 trial.

Conclusions

Our findings indicate that patient engagement in the development of an m-health intervention has the potential to improve adherence with both BD and HTN medications in individuals with known sub-optimal adherence. Patient engagement in health care is essential if we are to optimize patient outcomes.

Web-Based Tools and Mobile Applications To Mitigate Burnout, Depression, and Suicidality Among Healthcare Students and Professionals: a Systematic Review

OBJECTIVE

Being a healthcare professional can be a uniquely rewarding calling. However, the demands of training and practice can lead to chronic distress and serious psychological, interpersonal, and personal health burdens. Although higher burnout, depression, and suicide rates have been reported in healthcare professionals, only a minority receive treatment. Concerns regarding confidentiality, stigma, potential career implications, and cost and time constraints are cited as key barriers. Web-based and mobile applications have been shown to mitigate stress, burnout, depression, and suicidal ideation among several populations and may circumvent these barriers. Here, we reviewed published data on such resources and selected a small sample that readily can be used by healthcare providers.

METHODS

We searched PubMed for articles evaluating stress, burnout, depression, and suicide prevention or intervention for healthcare students or providers and identified five categories of programs with significant effectiveness: Cognitive Behavioral Therapy (online), meditation, mindfulness, breathing, and relaxation techniques. Using these categories, we searched for Web-based (through Google and beacon.anu.edu.au -a wellness resource website) and mobile applications (Apple and mobile. va.gov/appstore ) for stress, burnout, depression, and suicide prevention and identified 36 resources to further evaluate based on relevance, applicability to healthcare providers (confidentiality, convenience, and cost), and the strength of findings supporting their effectiveness.

RESULTS

We selected seven resources under five general categories designed to foster wellness and reduce burnout, depression, and suicide risk among healthcare workers: breathing (Breath2Relax), meditation (Headspace, guided meditation audios), Web-based Cognitive Behavioral Therapy (MoodGYM, Stress Gym), and suicide prevention apps (Stay Alive, Virtual Hope Box).

CONCLUSIONS

This list serves as a starting point to enhance coping with stressors as a healthcare student or professional in order to help mitigate burnout, depression, and suicidality. The next steps include adapting digital health strategies to specifically fit the needs of healthcare providers, with the ultimate goal of facilitating in-person care when warranted.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study

OBJECTIVE

To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia.

METHODS

Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use.

RESULTS

All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use.

CONCLUSION

Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

Modified Mediterranean Diet for Enrichment of Short Chain Fatty Acids: Potential Adjunctive Therapeutic to Target Immune and Metabolic Dysfunction in Schizophrenia?

Growing interest in gut and digestive processes and their potential link to brain and peripheral based inflammation or biobehavioral phenotypes has led to an increasing number of basic and translational scientific reports focused on the role of gut microbiota within the context of neuropsychiatric disorders. However, the effect of dietary modification on specific gut metabolites, in association with immune, metabolic, and psychopathological functioning in schizophrenia spectrum disorders has not been well characterized. The short chain fatty acids (SCFA) acetate, butyrate, and propionate, major metabolites derived from fermentation of dietary fibers by gut microbes, interact with multiple immune and metabolic pathways. The specific pathways that SCFA are thought to target, are dysregulated in cardiovascular disease, type II diabetes, and systemic inflammation. Most notably, these disorders are consistently linked to an attenuated lifespan in schizophrenia. Although, unhealthy dietary intake patterns and increased prevalence of immune and metabolic dysfunction has been observed in people with schizophrenia; dietary interventions have not been well utilized to target immune or metabolic illness. Prior schizophrenia patient trials primarily focused on the effects of gluten free diets. Findings from these studies indicate that a diet avoiding gluten benefits a limited subset of patients, individuals with celiac disease or non-celiac gluten sensitivity. Therefore, alternative dietary and nutritional modifications such as high-fiber, Mediterranean style, diets that enrich the production of SCFA, while being associated with a minimal likelihood of adverse events, may improve immune and cardiovascular outcomes linked to premature mortality in schizophrenia. With a growing literature demonstrating that SCFA can cross the blood brain barrier and target key inflammatory and metabolic pathways, this article highlights enriching dietary intake for SCFA as a potential adjunctive therapy for people with schizophrenia.

Technology-Based Early Warning Systems for Bipolar Disorder: A Conceptual Framework

Recognition and timely action around "warning signs" of illness exacerbation is central to the self-management of bipolar disorder. Due to its heterogeneity and fluctuating course, passive and active mobile technologies have been increasingly evaluated as adjunctive or standalone tools to predict and prevent risk of worsening of course in bipolar disorder. As predictive analytics approaches to big data from mobile health (mHealth) applications and ancillary sensors advance, it is likely that early warning systems will increasingly become available to patients. Such systems could reduce the amount of time spent experiencing symptoms and diminish the immense disability experienced by people with bipolar disorder. However, in addition to the challenges in validating such systems, we argue that early warning systems may not be without harms. Probabilistic warnings may be delivered to individuals who may not be able to interpret the warning, have limited information about what behaviors to change, or are unprepared to or cannot feasibly act due to time or logistic constraints. We propose five essential elements for early warning systems and provide a conceptual framework for designing, incorporating stakeholder input, and validating early warning systems for bipolar disorder with a focus on pragmatic considerations.

The Validity of a Brief Risk Assessment Tool for Predicting Suicidal Behavior in Veterans Utilizing VHA Mental Health Care

Suicide risk among military veterans is an important and ongoing concern. The Veterans Administration (VA) mandates suicide risk screening of all veterans seen for mental health issues, but little is known about the effectiveness of this screening. A retrospective chart review to examine all suicide risk screens at VA San Diego between October and December 2012 (n = 3,365) was conducted to assess whether results were associated with suicidal behavior over the subsequent 12 months. Patients judged to be at increased risk for suicide were 3 to 16 times more likely to attempt suicide and 7 to 25 times more likely to engage in self-directed violence over the next 12 months compared with others. The screening tool may be a useful addition to clinical practice.

Feasibility and Acceptability of Smartphone Assessment in Older Adults with Cognitive and Emotional Difficulties

OBJECTIVES

Ecological momentary assessment (EMA) has several advantages in clinical research yet little is known about the feasibility of collecting EMA data with mobile technologies in older adults, particularly those with emotional or cognitive difficulties. The aim of this feasibility study was to assess perceived acceptability, adherence rates, and reasons for non-adherence to smartphone-based EMA.

METHOD

At two sites, participants (n=103) aged 65 years or older with a DSM-IV-defined anxiety or depressive disorder and cognitive concerns responded three times daily to smartphone-based EMA questions assessing clinical outcomes for two 10-day periods. Quantitative and qualitative measures assessed acceptability, adherence, and reasons for non-adherence following both 10-day EMA periods.

RESULTS

Participants were moderately satisfied with and comfortable using smartphone-based EMA. Overall, 76% of participants completed surveys on ≥10 of the 20 assessment days, and 70% of participants completed at least 30% of the total surveys. Reasons for non-adherence included technical (malfunction), logistical (competing demands), physiological (hearing difficulties), and cognitive (forgetting) issues.

DISCUSSION

Smartphone-based EMA is feasible in older adults with cognitive and emotional difficulties. EMA tools should be responsive to the needs and preferences of participants to ensure adequate acceptability and adherence in this population. Our findings can inform the design, development, and implementation of mobile technologies in older adults in research and clinical contexts.

Feasibility randomised controlled trial of Recovery-focused Cognitive Behavioural Therapy for Older Adults with bipolar disorder (RfCBT-OA): study protocol

INTRODUCTION

Bipolar disorder is a severe and chronic mental health problem that persists into older adulthood. The number of people living with this condition is set to rise as the UK experiences a rapid ageing of its population. To date, there has been very little research or service development with respect to psychological therapies for this group of people.

METHODS AND ANALYSIS

A parallel two-arm randomised controlled trial comparing a 14-session, 6-month Recovery-focused Cognitive-Behavioural Therapy for Older Adults with bipolar disorder (RfCBT-OA) plus treatment as usual (TAU) versus TAU alone. Participants will be recruited in the North-West of England via primary and secondary mental health services and through self-referral. The primary objective of the study is to evaluate the feasibility and acceptability of RfCBT-OA; therefore, a formal power calculation is not appropriate. It has been estimated that randomising 25 participants per group will be sufficient to be able to reliably determine the primary feasibility outcomes (eg, recruitment and retention rates), in line with recommendations for sample sizes for feasibility/pilot trials. Participants in both arms will complete assessments at baseline and then every 3 months, over the 12-month follow-up period. We will gain an estimate of the likely effect size of RfCBT-OA on a range of clinical outcomes and estimate parameters needed to determine the appropriate sample size for a definitive, larger trial to evaluate the effectiveness and cost-effectiveness of RfCBT-OA. Data analysis is discussed further in the Analysis section in the main paper.

ETHICS AND DISSEMINATION

This protocol was approved by the UK National Health Service (NHS) Ethics Committee process (REC ref: 15/NW/0330). The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and local, participating NHS trusts.

TRIAL REGISTRATION NUMBER

ISRCTN13875321; Pre-results.

Associations of high sensitivity C-reactive protein levels in schizophrenia and comparison groups

Schizophrenia is characterized by physical (mainly metabolic and cardiovascular) comorbidity and shortened lifespan. High sensitivity C-reactive protein (hs-CRP), an inflammatory marker of hepatic origin linked to metabolic and cardiovascular diseases and mortality in the general population, has been reported to be elevated in people with schizophrenia. However, the relationship of hs-CRP to psychiatric and medical risk factors, after controlling for potentially confounding variables such as smoking, is not well established in schizophrenia. We assessed hs-CRP levels along with various demographic, psychiatric, and metabolic measures in 88 clinically stable outpatients with schizophrenia or schizoaffective disorder and 71 age epoch-matched comparison subjects with no history of a major psychiatric illness. hs-CRP levels were significantly higher in individuals with schizophrenia than in comparison subjects. Higher hs-CRP levels in the schizophrenia group were associated with female gender, more severe negative symptoms, greater medical comorbidity, and worse metabolic risk factors including BMI, fasting glucose, and hemoglobin A1c levels. hs-CRP was not related to age, race, education, smoking status, antipsychotic dosage, or cognitive impairment. Longitudinal studies are needed to investigate the relationship between hs-CRP and long-term health outcomes including metabolic syndrome, cardiovascular disease, and mortality in schizophrenia.

Factors influencing self-assessment of cognition and functioning in bipolar disorder: a preliminary study

INTRODUCTION

Self-assessment deficits are common in schizophrenia and span multiple aspects of functioning, including awareness of symptoms, and the ability to assess objective levels of cognitive deficits and everyday functioning. Whereas impaired awareness of illness in bipolar disorder during symptomatic periods is well understood, awareness of disability and cognitive deficits has been less well studied.

METHODS

In this pilot study, 30 patients with a lifetime history of bipolar I disorder and current bipolar depression completed performance-based tests of cognition and functional capacity and self-reported their opinions of their cognitive abilities, everyday functioning and symptoms. High contact clinicians also provided impressions of the patients' cognitive performance and everyday functioning.

RESULTS

Clinician impressions of cognition and everyday functioning were correlated with the results of the performance-based assessments, whereas the patient self-reports of cognition and functioning were uncorrelated both with their own performance and with the clinician impressions. However, severity of depressive symptoms was correlated with self-reports of functioning in cognitive and functional domains, but not with either performance-based data or clinician impressions of cognition or functioning.

CONCLUSIONS

Depression appears to be a factor affecting self-assessment in bipolar disorder and reports of cognition and functioning were minimally related to objective information and clinician impressions. Symptoms of mania were minimal and not correlated with performance-based assessments or clinician impressions.

Candidate SNP associations of optimism and resilience in older adults: exploratory study of 935 community-dwelling adults

OBJECTIVE

Optimism and resilience promote health and well-being in older adults, and previous reports suggest that these traits are heritable. We examined the association of selected single-nucleotide polymorphisms (SNPs) with optimism and resilience in older adults.

DESIGN

Candidate gene association study that was a follow-on at the University of California, San Diego, sites of two NIH-funded multi-site longitudinal investigations: Women's Health Initiative (WHI) and SELenium and vitamin E Cancer prevention Trial (SELECT).

PARTICIPANTS

426 women from WHI older than age 50 years, and 509 men older than age 55 years (age 50 years for African American men) from SELECT.

MEASUREMENTS

65 candidate gene SNPs that were judged by consensus, based on a literature review, as being related to predisposition to optimism and resilience, and 31 ancestry informative marker SNPs, genotyped from blood-based DNA samples and self-report scales for trait optimism, resilience, and depressive symptoms.

RESULTS

Using a Bonferroni threshold for significant association (p = 0.00089), there were no significant associations for individual SNPs with optimism or resilience in single-locus analyses. Exploratory multi-locus polygenic analyses with p <0.05 showed an association of optimism with SNPs in MAOA, IL10, and FGG genes, and an association of resilience with a SNP in MAOA gene.

CONCLUSIONS

Correcting for Type I errors, there were no significant associations of optimism and resilience with specific gene SNPs in single-locus analyses. Positive psychological traits are likely to be genetically complex, with many loci having small effects contributing to phenotypic variation. Our exploratory multi-locus polygenic analyses suggest that larger sample sizes and complementary approaches involving methods such as sequence-based association studies, copy number variation analyses, and pathway-based analyses could be useful for better understanding the genetic basis of these positive psychological traits.

Strategies for successful aging: a research update

Population aging is an enormous public health issue and there is clear need for strategies to maximize opportunities for successful aging. Many psychiatric illnesses are increasingly thought to be associated with accelerated aging, therefore emerging data on individual and policy level interventions that alter typical aging trajectories are relevant to mental health practitioners. Although the determinants and definition of successful aging remain controversial, increasing data indicate that psychiatric illnesses directly impact biological aging trajectories and diminish lifestyle, psychological, and socio-environmental factors that seem to reduce risk of morbidity and mortality. Many interventions designed to enhance the normal course of aging may be adjunctive approaches to management of psychiatric illnesses. We highlight recent data on interventions seeking to promote healthy aging, such as cognitive remediation, physical activity, nutrition, and complementary and alternative treatments for older people with and without psychiatric illnesses.

Summer research training for medical students: impact on research self-efficacy

There is a well-documented shortage of physician researchers, and numerous training programs have been launched to facilitate development of new physician scientists. Short-term research training programs are the most practical form of research exposure for most medical students, and the summer between their first and second years of medical school is generally the longest period they can devote solely to research. The goal of short-term training programs is to whet the students' appetite for research and spark their interest in the field. Relatively little research has been done to test the effectiveness of short-term research training programs. In an effort to examine short-term effects of three different NIH-funded summer research training programs for medical students, we assessed the trainees' (N = 75) research self-efficacy prior to and after the programs using an 11-item scale. These hands-on training programs combined experiential, didactic, and mentoring elements. The students demonstrated a significant increase in their self-efficacy for research. Trainees' gender, ranking of their school, type of research, and specific content of research project did not predict improvement. Effect sizes for different types of items on the scale varied, with the largest gain seen in research methodology and communication of study findings.

Computer use among patients with age-related macular degeneration

PURPOSE

Age-related macular degeneration (AMD) is the leading cause of incurable vision loss in older adults in industrialized countries and is on a trajectory to disable a growing number of persons as societies age. To assess the potential of using telemedicine for expansion of an in-person AMD self-management program, we examined the extent of computer use in a sample of older adults with AMD.

METHODS

160 older adult volunteers (mean age = 76 years; female = 51%) with AMD (mean visual acuity in better eye: 20/40; worse eye: 20/90) were randomly selected from members of the San Diego County AMD Registry. Computer use was assessed with a Health and Impact Questionnaire. Dependent measures were Snellen visual acuity, National Eye Institute-Visual Function Questionnaire, the AMD Self-Efficacy Questionnaire, and the Geriatric Depression Scale.

RESULTS

Overall 70.6% reported computer use at least once per month. By age and gender stratum, 76.5% of men aged 60-74 years, 73.3% of men aged 75 years and over, 74.3% of women aged 60-74 years, and 60.9% of women aged 75 years and over used computers. In logistic regression analyses controlling for age and gender, computer use was associated with better visual acuity (P = 0.029), higher education (P = 0.002), and self-efficacy for communication (P = 0.027).

CONCLUSION

The majority of older adults with AMD in our sample used computers, with use highest among more educated and visually intact patients. Computer use to access the Internet is feasible in AMD patients and should be encouraged. The inclusion of computer use in measures of AMD-related functioning appears warranted.