Ian Fellows

Is late‐onset schizophrenia a subtype of schizophrenia?

Vahia IV, Palmer BW, Depp C, Fellows I, Golshan S, Kraemer HC, Jeste DV. Is late‐onset schizophrenia a subtype of schizophrenia?

Multimedia Consent for Research in People With Schizophrenia and Normal Subjects: a Randomized Controlled Trial

Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.

Physical and mental health-related quality of life among older people with schizophrenia.

OBJECTIVE Since the time of Kraeplin, schizophrenia has been thought of as a disorder with progressive deterioration in functioning. An important aspect of functioning is both physical and mental health-related quality of life (HRQoL). The objective of this study was to examine the relationship of age to both mental and physical aspects of HRQoL in individuals with schizophrenia as compared to normal comparison subjects (NCs). METHODS Middle-aged and older community-dwelling patients with schizophrenia (N=486) were compared to NCs (N=101). Health related quality of life was measured using the SF-36 Physical Health and Mental Health Component scores. The relationship between age and HRQoL was examined using linear regressions. In addition, we performed exploratory analyses to examine the effects of confounding variables on this relationship, and to examine the effects of age on SF-36 subscales. RESULTS Patients with schizophrenia had lower SF-36 Physical and Mental Health Component scores than NCs, and these differences persisted after adjusting for the age difference between the two groups. The relationship between age and mental, but not physical, HRQoL was significantly different between the patients with schizophrenia and the NCs. Specifically, older age was associated with higher mental HRQoL among patients with schizophrenia, but not among the NCs. This difference remained significant after examining multiple potential confounding demographic and clinical variables. CONCLUSIONS This study found that older age was associated with greater mental health quality of life. Longitudinal studies are warranted to confirm our finding, and to examine potential mechanisms responsible for possible improvement in mental HRQoL with age.

Correlates of spirituality in older women

Introduction: The role of spirituality in the context of mental health and successful aging is not well understood. In a sample of community-dwelling older women enrolled at the San Diego site of the Womens Health Initiative study, we examined the association between spirituality and a range of variables associated with successful cognitive and emotional aging, including optimism, resilience, depression, and health-related quality of life (HRQoL). Methods: A detailed cross-sectional survey questionnaire on successful aging was completed by 1973 older women. It included multiple self-reported measures of positive psychological functioning (e.g., resilience and optimism), as well as depression and HRQoL. Spirituality was measured using a five-item self-report scale constructed using two items from the Brief Multidimensional Measure of Religiosity/Spirituality and three items from Hoges Intrinsic Religious Motivation Scale. Results: Overall, 40% women reported regular attendance in organized religious practice, and 53% reported engaging in private spiritual practices. Several variables were significantly related to spirituality in bivariate associations; however, using model testing, spirituality was significantly associated only with higher resilience, lower income, lower education, and lower likelihood of being in a marital or committed relationship. Conclusions: Our findings point to a role for spirituality in promoting resilience to stressors, possibly to a greater degree in persons with lower income and education level. Future longitudinal studies are needed to confirm these associations.

Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia

The quality of life (QOL) for individuals with schizophrenia is determined by a number of factors, not limited to symptomatology. The current study examined lack of insight as one such factor that may influence subjective QOL or functional capacity. It was hypothesized that insight would significantly interact with symptom severity to influence subjective QOL. Insight was not expected to influence the relation between symptom severity and functional capacity.

Treatment of subsyndromal depressive symptoms in middle-aged and older adults with schizophrenia: effect on functioning.

Subsyndromal symptoms of depression (SSD) in patients with schizophrenia are common and clinically important. SSRIs appear to be helpful in alleviating depressive symptoms in patients with schizophrenia who have SSD in patients age 40 and greater. It is not known whether SSRIs help improve functioning in this population. We hypothesized that treating this population with the SSRI citalopram would lead to improvements in social, mental and physical functioning as well as improvements in medication management and quality of life.

Do people with schizophrenia have differential impairment in episodic memory and/or working memory relative to other cognitive abilities?

Efforts to identify differential or core cognitive deficits in schizophrenia have been made for several decades, with limited success. Part of the difficulty in establishing a cognitive profile in schizophrenia is the considerable inter-patient heterogeneity in the level of cognitive impairment. Thus, it may be useful to examine the presence of relative cognitive weaknesses on an intra-person level. In the present study we examined the rates of significant intra-person differences between crystallized verbal ability versus five other cognitive abilities among 127 persons with schizophrenia or schizoaffective disorder and 127 demographically matched normal comparison (NC) subjects. We found that the rates of significant discrepancies above the NC group base-rates was significantly greater in reference to those discrepancies involving visual memory relative to those associated with auditory memory, working memory, processing speed, and perceptual organization. The findings conflict with prior suggestions that working memory or auditory episodic memory are differential or core deficits in schizophrenia, and highlight the importance of considering visual memory in characterizing the cognitive effects of this condition.

Functioning in Middle Aged and Older Patients With Schizophrenia and Depressive Symptoms: Relationship to Psychopathology

BACKGROUND Depressive symptoms are common in middle aged and older patients with schizophrenia. The authors hypothesized that worse functioning in these patients would be associated with worse psychopathology. METHODS Outpatients with schizophrenia were > or =40 years old with subsyndromal depression and Hamilton Depression Rating Scale Scores of > or =8. Exclusions were dementia, two months of either mania or major depression or 1 month active substance abuse/dependence. The authors administered performance based functional assessments, the Positive and Negative Syndrome Scale of Schizophrenia [PANSS], and Calgary Depression Rating Scale. RESULTS PANSS (-) scores were negatively correlated with the UCSD Performance Skills Based Assessment, Social Skills Performance Assessment and Medication Management Ability Assessment total error (MMAA) scores. Digit symbol scores served as a moderator of the relationship between MMAA and PANSS (-) scores. CONCLUSIONS Negative symptoms were associated with functioning. The relationship between negative symptoms and medication errors seem to weaken in subjects with quicker processing speed.

Depression in Premedical Undergraduates: A Cross-Sectional Survey

BACKGROUND Medical students and residents are known to have high rates of depression, a common stress-related challenge that impairs quality of life and job satisfaction and predisposes those affected to general medical illness. Our primary hypothesis was that premedical students would exhibit greater depressive symptoms than nonpremedical students. A secondary aim was to explore the interactions of premedical student status with gender and ethnicity in the context of depression. METHOD In this cross-sectional study 647 premedical and 1,495 nonpremedical undergraduates at the University of California, San Diego, were surveyed to examine whether seeds of depression can be identified even before formal medical training. Participants completed a series of demographic questions along with the 9-item Patient Health Questionnaire to gauge depression intensity. The survey was made available online for a period of 3 months from March 2009-June 2009. RESULTS Premedical students were more likely to meet screening criteria suggestive of the presence of major depressive disorder and to exhibit more severe depression than nonpremedical students. Female premedical students exhibited greater depression than female nonpremedical students and males in general. Hispanic premedical students, in particular, had a greater prevalence of depression and greater intensity of depressive symptoms than other premedical students and Hispanic nonpremedical students. No differences were found in current, past, or family history between premedical and nonpremedical students. CONCLUSIONS These findings underscore the importance of understanding the unique strains and mental health consequences of a premedical curriculum, especially for women and certain minority ethnic populations. A meaningful next step would be a larger study, conducted by several representative university campuses, to confirm these findings; a follow-up of these cohorts could track longitudinal progress. More research must be done to determine the etiology of these findings with the ultimate intention of identifying opportunities for prevention and early intervention, which may provide significant public health payoffs in the long run.

Treatment of Subsyndromal Depressive Symptoms in Middle-Age and Older Patients With Schizophrenia: Effect of Age on Response

OBJECTIVE The authors hypothesized that age would moderate the response of patients with schizophrenia and subsyndromal depression (SSD) treated citalopram with depressive symptoms and other outcomes. Also, older patients would exhibit more side effects with citalopram. METHODS Participants of 40 years or older had schizophrenia or schizoaffective disorder with SSD. Patients randomly received flexible dosing of citalopram or placebo augmentation of their antipsychotic medication. Linear regression determined whether age had any moderating effect on depressive symptoms, global psychopathology, negative symptoms, mental functioning, and quality of life. Age-related side effects were examined. RESULTS There were no significant drug group by age interaction in depressive or psychotic symptoms, mental Short Form-12, or quality of life scores. Similarly, there were few age-related side effect differences. CONCLUSION Symptoms in younger and older patients with schizophrenia and SSD treated with citalopram seem to respond similarly. Adverse events do not seem to differ with age.