Kevin L. Rand

A PROSPECTIVE EVALUATION OF THE DIRECTIONALITY OF THE DEPRESSION-INFLAMMATION RELATIONSHIP

Cross-sectional studies have found that individuals with depressive disorders or symptoms have elevated levels of inflammatory markers predictive of coronary artery disease, including interleukin-6 (IL-6) and C-reactive protein (CRP). Due to the paucity of prospective studies, however, the directionality of the depression-inflammation relationship is unclear. We evaluated the longitudinal associations between depressive symptoms and both IL-6 and CRP among 263 healthy, older men and women enrolled in the Pittsburgh Healthy Heart Project, a 6-year prospective cohort study. During the baseline and follow-up visits, participants completed the Beck Depression Inventory-II (BDI-II) to assess depressive symptoms and underwent blood draws to quantify serum IL-6 and CRP. Path analyses revealed that baseline BDI-II (beta=0.18, p=0.01, DeltaR(2)=0.02) was a predictor of 6-year change in IL-6, even after adjustment for demographic, biomedical, and behavioral factors as well as other negative emotions. Of all the factors examined, only body-mass index was a stronger predictor of IL-6 change than depressive symptoms. In contrast to these results, baseline IL-6 did not predict 6-year change in BDI-II. Evidence of a weak bidirectional relationship between BDI-II and CRP was also observed; however, neither of these longitudinal associations was significant. The present findings indicate that depressive symptoms may precede and augment some inflammatory processes relevant to coronary artery disease among healthy, older adults. Therefore, our results imply that depression may lead to inflammation and that inflammation may be one of the mechanisms through which depression contributes to cardiovascular risk.

Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression

OBJECTIVE This study is an examination of sleep, pain, depression, and physical functioning at baseline and 1-year followup among patients with fibromyalgia syndrome (FMS). Although it is clear that these symptoms are prevalent among FMS patients and that they are related, the direction of the relationship is unclear. We sought to identify and report sleep problems in this population and to examine their relationship to pain, depression, and physical functioning. METHODS Patients diagnosed with fibromyalgia were recruited from a Southern California health maintenance organization and evaluated according to American College of Rheumatology criteria in the research laboratory. Six hundred patients completed the baseline assessment and 492 completed the 1-year assessment. Measures included the Center for Epidemiologic Studies Depression Scale, the McGill Pain Questionnaire, the Pittsburgh Sleep Quality Index, and the Fibromyalgia Impact Questionnaire. RESULTS The majority of the sample (96% at baseline and 94.7% at 1 year) scored within the range of problem sleepers. Path analyses examined the impact of baseline values on 1-year values for each of the 4 variables. No variable of interest predicted sleep, sleep predicted pain (beta = 0.13), pain predicted physical functioning (beta = -0.13), and physical functioning predicted depression (beta = -0.10). CONCLUSION These findings highlight the high prevalence of sleep problems in this population and suggest that they play a critical role in exacerbating FMS symptoms. Furthermore, they support limited existing findings that sleep predicts subsequent pain in this population, but also extend the literature, suggesting that sleep may be related to depression through pain and physical functioning.

Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders

Lysaker PH, Shea AM, Buck KD, Dimaggio G, Nicolò G, Procacci M, Salvatore G, Rand KL. Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders.

AUTHORS' RESPONSE: Somewhere Over the Rainbow: Hope Theory Weathers Its First Decade

We appreciate the opportunity to discuss the current state of hope theory with so many of our renowned colleagues. It is a luxury to have nine experts comment on hope theory. It allows those of us in the Hope Research Group to examine carefully the theory that we have developed and tested over the last decade. To facilitate our responding to the commentators, we have grouped their various points together, and take up each of these issues separately.

Longitudinal relationships between fatigue and depression in cancer patients with depression and/or pain.

OBJECTIVE Fatigue is one of the most common and debilitating symptoms reported by cancer patients, yet relatively little is understood about its etiology. Recently, as researchers have begun to focus attention on cancer-related fatigue (CRF), depression has emerged as its strongest correlate. Few longitudinal studies, however, have examined directionality of the relationship between the two symptoms. Our aim was to evaluate the directionality of the association between depression and CRF. METHOD The study used a single-group cohort design of longitudinal data (N = 329) from a randomized controlled trial of an intervention for pain and depression in a heterogeneous sample of cancer patients. Participants met criteria for clinically significant pain and/or depression. Our hypothesis that depression would predict change in fatigue over 3 months was tested using latent variable cross-lagged panel analysis. RESULTS Depressive symptoms and fatigue were strongly correlated in the sample (baseline correlation of latent variables = 0.71). Although the model showed good fit to the data, χ(2) (66, N = 329) = 88.16, p = .04, SRMR = 0.030, RMSEA = 0.032, and CFI = 1.00, neither structural path linking depression and fatigue was significant, suggesting neither symptom preceded and predicted the other. CONCLUSIONS Our findings did not support hypotheses regarding the directionality of the relationship between depressive symptoms and fatigue. The clinical implication is that depression-specific treatments may not be sufficient to treat CRF and that instead, interventions specifically targeting fatigue are needed.

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer‐reviewed, English‐language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full‐text, English‐language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality.

Life goals in patients with cancer: A systematic review of the literature

Purposes of this systematic review of life goal research in cancer patients were to (1) identify life goal characteristics and processes being examined, (2) describe instruments used to assess life goal constructs, (3) identify theoretical models being used to guide research, and (4) summarize what is known about the impact of the cancer experience on life goal characteristics, processes, and psychological outcomes.

Intrinsic motivation as a mediator between metacognition deficits and impaired functioning in psychosis.

OBJECTIVE Poor functioning has long been observed in individuals with psychosis. Recent studies have identified metacognition - ones ability to form complex ideas about oneself and others and to use that information to respond to psychological and social challenges-as being an important determinant of functioning. However, the exact process by which deficits in metacognition lead to impaired functioning remains unclear. This study first examined whether low intrinsic motivation, or the tendency to pursue novel experiences and to engage in self-improvement, mediates the relationship between deficits in metacognition and impaired functioning. We then examined whether intrinsic motivation significantly mediated the relationship when controlling for age, education, symptoms, executive functioning, and social cognition. DESIGN Mediation models were examined in a cross-sectional data set. METHODS One hundred and seventy-five individuals with a psychotic disorder completed interview-based measures of metacognition, intrinsic motivation, symptoms, and functioning and performance-based measures of executive functioning and social cognition. RESULTS Analyses revealed that intrinsic motivation mediated the relationship between metacognition deficits and impaired functioning (95% CI of indirect effect [0.12-0.43]), even after controlling for the aforesaid variables (95% CI of indirect effect [0.04-0.29]). CONCLUSIONS Results suggest that intrinsic motivation may be a mechanism that underlies the link between deficits in metacognition and impaired functioning and indicate that metacognition and intrinsic motivation may be important treatment targets to improve functioning in individuals with psychosis. PRACTITIONER POINTS The findings of this study suggest that deficits in metacognition may indirectly lead to impaired functioning through their effect on intrinsic motivation in individuals with psychosis. Psychological treatments that target deficits in both metacognition and intrinsic motivation may help to alleviate impaired functioning in individuals with psychosis. LIMITATIONS The cross-sectional design of this study is a limitation, and additional longitudinal studies are needed to confirm the direction of the findings and rule out rival hypotheses. Generalization of the findings may be limited by the sample composition. It may be that different relationships exist between metacognition, intrinsic motivation, and functioning in those with early psychosis or among those in an acute phase or who decline treatment.

Medical Students' Professionalism Narratives Reveal That Experiences With Death, Dying, or Palliative Care Are More Positive Than Other Experiences During Their Internal Medicine Clerkship.

Purpose: More physicians need to acquire the skills of primary palliative care. Medical students’ clerkship experiences with death, dying, and palliative care (DDPC), however, may create barriers to learning such skills during residency. Whether professional development is differentially affected by DDPC is unknown. This knowledge gap potentially hinders the development of educational strategies to optimize students’ preparedness for primary palliative care. Method: Third-year students submitted professionalism narratives (N = 4062) during their internal medicine clerkship between 2004 and 2011. We identified DDPC-related narratives and then randomly selected control narratives. Narratives were compared by valence (positive or negative) and professionalism-related themes. Results and Conclusion: Less than 10% of the narratives were related to DDPC, but the majority was positive. There was a significant overlap in professionalism themes between DDPC and control narratives. The results suggest student preparedness for primary palliative care may be improved by addressing the common professionalism challenges of clinical clerkships.

Sleep disorders in breast cancer survivors

PurposeThe purpose of this study was to evaluate the feasibility, acceptability, and initial results of a structured assessment of sleep disorders in breast cancer survivors (BCS). Our goal was to determine whether the assessment could be easily used and whether it would capture problems suggestive of one or more underlying sleep disorders that require referral to a specialist for diagnostic validation through polysomnography and appropriate specialty treatment.MethodsA cross-sectional, feasibility study using convenience sampling.ResultsA total of 38 BCS completed the study. Recruitment procedures were adequate in finding eligible BCS, however, procedures used to establish possible patterns of sleep disorders (e.g., interview) were not feasible for screening for sleep disorders in the clinical setting due to the time it took to complete each interview. A total of seven sleep disorder categories were identified in the data with the majority of women having at least one possible sleep disorder.ConclusionsStudy findings suggest that population-based screening for sleep disorders in clinical practice should be a priority for BCS reporting chronic sleep problems.