Colin A. Depp

The expert consensus guideline series

Abstract Over the past decade, many new epilepsy treatments have been approved in the United States, promising better quality of life for many with epilepsy. However, clinicians must now choose among a growing number of treatment options and possible combinations. Randomized clinical trials (RCTs) form the basis for evidence-based decision making about best treatment options, but they rarely compare active therapies, making decisions difficult. When medical literature is lacking, expert opinion is helpful, but may contain potential biases. The expert consensus method is a new approach for statistically analyzing pooled opinion to minimize biases inherent in other systems of summarizing expert opinion. We used this method to analyze expert opinion on treatment of three epilepsy syndromes (idiopathic generalized epilepsy, symptomatic localization-related epilepsy, and symptomatic generalized epilepsy) and status epilepticus. For all three syndromes, the experts recommended the same general treatment strategy. As a first step, they recommend monotherapy. If this fails, a second monotherapy should be tried. Following this, the experts are split between additional trials of monotherapy and a combination of two therapies. If this fails, most agree the next step should be additional trials of two therapies, with less agreement as to the next best step after this. One exception to these recommendations is that the experts recommend an evaluation for epilepsy surgery after the third failed step for symptomatic localization-related epilepsies. The results of the expert survey were used to develop user-friendly treatment guidelines concerning overall treatment strategies and choice of specific medications for different syndromes and for status epilepticus.

Prediction of Real World Functional Disability in Chronic Mental Disorders: A Comparison of Schizophrenia and Bipolar Disorder

OBJECTIVE Schizophrenia and bipolar disorder are associated with multidimensional disability. This study examined differential predictors of functional deficits in the two disorders. METHOD Community-dwelling individuals with schizophrenia (N=161) or bipolar disorder (N=130) were assessed with neuropsychological tests, symptom measures, and performance-based social and adaptive (i.e., everyday living skills) functional competence measures as well as three domains of real-world functioning: community and household activities; work skills; and interpersonal relationships. The authors used confirmatory path analysis to find the best-fitting models to examine the direct and indirect (as mediated by competence) prediction of the three domains of real-world functioning. RESULTS In all models for both groups, neurocognitions relationship with outcomes was largely mediated by competence. Symptoms were negatively associated with outcomes but unassociated with competence, with the exception of depression, which was a direct and mediated (through social competence) predictor in bipolar disorder. In both groups, neurocognition was related to activities directly and through a mediated relationship with adaptive competence. Work skills were directly and indirectly (through mediation with social competence) predicted by neurocognition in schizophrenia and entirely mediated by adaptive and social competence in bipolar disorder. Neurocognition was associated with interpersonal relationships directly in the schizophrenia group and mediated by social competence in both groups. CONCLUSIONS Although there was greater disability in schizophrenia, neurocognition predicted worse functioning in all outcome domains in both disorders. These results support the shared role of neurocognition in bipolar disorder and schizophrenia in producing disability, with predictive differences between disorders in domain-specific effects of symptoms and social and adaptive competence.

Measurement and predictors of resilience among community-dwelling older women

BACKGROUND Resilience, the ability to adapt positively to adversity, may be an important factor in successful aging. However, the assessment and correlates of resilience in elderly individuals have not received adequate attention. METHOD A total of 1395 community-dwelling women over age 60 who were participants at the San Diego Clinical Center of the Womens Health Initiative completed the Connor-Davidson Resilience Scale (CD-RISC), along with other scales pertinent to successful cognitive aging. Internal consistency and predictors of the CD-RISC were examined, as well as the consistency of its factor structure with published reports. RESULTS The mean age of the cohort was 73 (7.2) years and 14% were Hispanic, 76% were non-Hispanic white, and nearly all had completed a high school education (98%). The mean total score on the CD-RISC was 75.7 (sd=13.0). This scale showed high internal consistency (Cronbachs alpha=0.92). Exploratory factor analysis yielded four factors (somewhat different from those previously reported among younger adults) that reflected items involving: (1) personal control and goal orientation, (2) adaptation and tolerance for negative affect, (3) leadership and trust in instincts, and (4) spiritual coping. The strongest predictors of CD-RISC scores in this study were higher emotional well-being, optimism, self-rated successful aging, social engagement, and fewer cognitive complaints. CONCLUSIONS Our study suggests that the CD-RISC is an internally consistent scale for assessing resilience among older women, and that greater resilience as assessed by the CD-RISC related positively to key components of successful aging.

Exergames for Subsyndromal Depression in Older Adults: A Pilot Study of a Novel Intervention

OBJECTIVES Subsyndromal depression (SSD) is several times more common than major depression in older adults and is associated with significant negative health outcomes. Physical activity can improve depression, but adherence is often poor. The authors assessed the feasibility, acceptability, and short-term efficacy and safety of a novel intervention using exergames (entertaining video games that combine game play with exercise) for SSD in older adults. METHODS Community-dwelling older adults (N = 19, aged 63-94 years) with SSD participated in a 12-week pilot study (with follow-up at 20-24 weeks) of Nintendos Wii sports, with three 35-minute sessions a week. RESULTS Eight-six percent of enrolled participants completed the 12-week intervention. There was a significant improvement in depressive symptoms, mental health-related quality of life (QoL), and cognitive performance but not physical health-related QoL. There were no major adverse events, and improvement in depression was maintained at follow-up. CONCLUSIONS The findings provide preliminary indication of the benefits of exergames in seniors with SSD. Randomized controlled trials of exergames for late-life SSD are warranted.

Mobile Interventions for Severe Mental Illness: Design and Preliminary Data from Three Approaches

Mobile devices can be used to deliver psychosocial interventions, yet there is little prior application in severe mental illness. We provide the rationale, design, and preliminary data from 3 ongoing clinical trials of mobile interventions developed for bipolar disorder or schizophrenia. Project 1 used a personal digital assistant to prompt engagement in personalized self-management behaviors based on real-time data. Project 2 employed experience sampling through text messages to facilitate case management. Project 3 was built on group functional skills training for schizophrenia by incorporating between-session mobile phone contacts with therapists. Preliminary findings were of minimal participant attrition, and no broken devices; yet, several operational and technical barriers needed to be addressed. Adherence was similar to that reported in nonpsychiatric populations, with high participant satisfaction. Therefore, mobile devices seem feasible and acceptable in augmenting psychosocial interventions for severe mental illness, with future research in establishing efficacy, cost effectiveness, and ethical and safety protocols.

Association Between Older Age and More Successful Aging: Critical Role of Resilience and Depression

OBJECTIVE There is growing public health interest in understanding and promoting successful aging. While there has been some exciting empirical work on objective measures of physical health, relatively little published research combines physical, cognitive, and psychological assessments in large, randomly selected, community-based samples to assess self-rated successful aging. METHOD In the Successful AGing Evaluation (SAGE) study, the authors used a structured multicohort design to assess successful aging in 1,006 community-dwelling adults in San Diego County, ages 50-99 years, with oversampling of people over 80. A modified version of random-digit dialing was used to recruit subjects. Evaluations included a 25-minute telephone interview followed by a comprehensive mail-in survey of physical, cognitive, and psychological domains, including positive psychological traits and self-rated successful aging, scaled from 1 (lowest) to 10 (highest). RESULTS The mean age of the respondents was 77.3 years. Their mean self-rating of successful aging was 8.2, and older age was associated with a higher rating, despite worsening physical and cognitive functioning. The best multiple regression model achieved, using all the potential correlates, accounted for 30% of the variance in the score for self-rated successful aging and included resilience, depression, physical functioning, and age (entering the regression model in that order). CONCLUSIONS Resilience and depression had significant associations with self-rated successful aging, with effects comparable in size to that for physical health. While no causality can be inferred from cross-sectional data, increasing resilience and reducing depression might have effects on successful aging as strong as that of reducing physical disability, suggesting an important role for psychiatry in promoting successful aging.

Meta-Analysis of the Association Between Cognitive Abilities and Everyday Functioning in Bipolar Disorder

Depp CA, Mausbach BT, Harmell AL, Savla GN, Bowie CR, Harvey PD, Patterson TL. Meta‐analysis of the association between cognitive abilities and everyday functioning in bipolar disorder. Bipolar Disord 2012: 14: 217–226.

Ethnicity and time to institutionalization of dementia patients: A comparison of latina and caucasian female family caregivers

Objectives: To compare rates of institutionalization of dementia patients cared for by Latina and Caucasian female caregivers and to explore which caregiver and care‐recipient characteristics predicted institutionalization.

Successful Aging: Focus on Cognitive and Emotional Health

We review the definitions, predictors, and biobehavioral determinants of successful aging, as well as the evidence for and mechanisms of underlying selected interventions to enhance cognitive and emotional health in older adults. Defining successful aging has proven difficult, with discrepancies seen among biomedical, psychological, and lay perspectives. Although consensus is lacking, a number of studies have examined the genetic, lifestyle, and social determinants of operationalized determinants of successful aging; qualitative examinations of the meaning of the construct have also been conducted. The determinants coincide with fundamental aspects of aging. Recent clinical trials suggest that caloric restriction, physical activity, cognitive intervention, stress reduction, and social programs may enhance cognitive and emotional health in older people.

Subthreshold Depression and Successful Aging in Older Women

OBJECTIVES Subthreshold depression (StD) is common in older adults and is associated with poor self-rated health. However, the impact of StD on broader indicators of successful aging, such as positive psychological constructs, cognitive functioning, or quality of well-being, has not been assessed. The authors compared persons with scores above and below a predetermined threshold on the Center for Epidemiological Studies Scale for Depression (CES-D) with nondepressed (ND) persons on measures of multiple domains associated with successful aging. DESIGN Cross-sectional survey-based psychological assessments. PARTICIPANTS A total of 1,979 community-dwelling older women participating in the Womens Health Initiative study. MEASUREMENTS ND was defined as a CES-D score below 8, StD as a score between 8 and 15, and CES-D Depression (CD) as a score of 16 or above. The study questionnaire consisted of multiple self-reported measures of positive psychological functioning (e.g., optimism and resilience), cognitive functioning and complaints, and quality of well-being. The authors also obtained a history of diagnosis, treatment, and hospitalization related to mental health problems. RESULTS Overall 20.2% of women met CES-D criteria for StD and 7% for CD. Women with StD had worse self-rated successful aging, worse physical and emotional functioning, lower optimism, more negative attitudes toward aging, lower personal mastery and self-efficacy, and greater anxiety and hostility than ND women but scored better on all these measures than women with CD. Subjects with StD also had higher self-reported rates of previous diagnosis, treatment, and hospitalization for mental health problems than the ND group. Subjects with StD with depressed mood and/or anhedonia were largely similar to those without these symptoms. CONCLUSIONS Mild-moderate levels of depressive symptoms that likely fall under a general category of StD were common and were associated with worse functioning on virtually every component of successful aging that the authors examined. StD represents a clinical entity that may affect the longitudinal course of successful aging for large numbers of persons and is a potential target for clinical intervention.