Laurie A. Lindamer

Assessment of Physical Activity in Middle-aged and Older Adults with Schizophrenia

BACKGROUND Regular physical activity (PA) decreases morbidity in the general population; yet, information about the amount and effects of PA in persons with schizophrenia is scant. To develop interventions to increase PA and to assess its potential benefits in this group, accurate measurement of PA is needed. The purpose of this study was to characterize PA and determine the test-retest reliability and concurrent validity of the Yale Physical Activity Scale (YPAS), a self-report measure, in persons with schizophrenia. METHODS PA was assessed with the YPAS, a scale of motivational readiness for PA, and accelerometry in middle-aged and older persons with a diagnosis of schizophrenia (n=54) and in a comparison group with no known psychiatric diagnosis (n=27). RESULTS On the YPAS measures, persons with schizophrenia reported on average 11 h per week of PA, whereas the non-psychiatric comparison group reported about 32 h per week. Only about 30% of schizophrenia subjects were classified as being regularly active relative to 62% of the comparison group on PA motivational stages of readiness. On the accelerometry measures, the schizophrenia group had lower levels of light activity than the comparison group, but there were no differences in moderate and vigorous activity or sedentary behavior. Only in the comparison group were there significant associations between YPAS and accelerometer variables. Several YPAS scores demonstrated high test-retest reliability in both groups, and concurrent validity was supported between the YPAS and PA motivational stages of readiness. CONCLUSIONS We found that the YPAS is a reliable measure of PA in schizophrenia for some indices. Although the YPAS demonstrated concurrent validity with other self-report measures, it did not demonstrate concurrent validity when compared to PA measured by accelerometry in persons with schizophrenia. Use of multiple measures, both subjective and objective, is recommended when assessing PA in schizophrenia.

Hormone replacement therapy in postmenopausal women with schizophrenia: positive effect on negative symptoms?

BACKGROUND Some studies of premenopausal women suggest that the severity of psychopathology associated with schizophrenia may be related to levels of estrogen. METHODS We examined psychopathology in community-dwelling postmenopausal women with schizophrenia who had received (n = 24) versus had never received (n = 28) hormone replacement therapy. RESULTS Users of hormone replacement therapy and nonusers did not differ significantly with respect to age, ethnicity, education, age of onset, duration of schizophrenia, global cognitive functioning, or neuroleptic-induced movement disorders. The hormone replacement therapy users received lower average daily doses of antipsychotic medication; they had similar levels of positive symptoms but significantly less severe negative symptoms compared with hormone replacement therapy nonusers, independent of differences in antipsychotic dosage. CONCLUSIONS Our results suggest that the use of hormone replacement therapy in conjunction with antipsychotic medication in postmenopausal women with schizophrenia may help reduce negative, but not positive, symptoms.

Differences in Clinical Features and Mental Health Service Use in Bipolar Disorder Across the Lifespan

OBJECTIVE Because of the scarcity of research in geriatric bipolar disorder, the authors examined the prevalence, clinical features, and service use of persons with bipolar disorder among older adults treated in a large public mental health system. METHODS From San Diego Countys Adult and Older-Adult Mental Health Services database (N=34,970, fiscal year 2002-2003), the authors selected patients with bipolar disorder, divided them into three age-groups (young: age 18-39, middle-aged: age 40-59, and elderly: age 60+) and compared them on demographic, clinical, and mental health service use characteristics. RESULTS The authors identified 2,903 patients who received services for bipolar disorder at least once during the fiscal year, accounting for a slightly lower proportion of diagnosis among elderly patients (7.0%) than middle-aged (8.7%) or younger groups (8.3%). Elderly patients were less likely to have substance use disorder comorbidity, but more likely to have a cognitive disorder diagnosis and lower global functioning scores than their younger counterparts. Elderly bipolar patients were less likely than younger groups to use inpatient, outpatient, and emergency room psychiatric care, but more likely to use case-management and conservator services. DISCUSSION Bipolar disorder was only slightly less common among elderly patients in a large, public mental health system, compared to younger age-groups. Available clinical data revealed a mixed picture of bipolar disorder in late life, with more functional and cognitive impairment and less substance use disorder comorbidity and use of acute psychiatric services. Our findings suggest that older adults with bipolar disorder have unique mental health service needs.

Incarceration Among Adults Who Are in the Public Mental Health System: Rates, Risk Factors, and Short-Term Outcomes

OBJECTIVE Incarceration of people with mental illness has become a major social, clinical, and economic concern, with an estimated 2.1 million incarcerations in 2007. Prior studies have primarily focused on mental illness rates among incarcerated persons. This study examined rates of and risk factors for incarceration and reincarceration, as well as short-term outcomes after incarceration, among patients in a large public mental health system. METHODS The data set included 39,463 patient records combined with 4,544 matching incarceration records from the county jail system during fiscal year 2005-2006. Risk factors for incarceration and reincarceration were analyzed with logistic regression. Time after release from the index incarceration until receiving services was examined with survival analysis. RESULTS During the year, 11.5% of patients (N=4,544) were incarcerated. Risk factors for incarceration included prior incarcerations; co-occurring substance-related diagnoses; homelessness; schizophrenia, bipolar, or other psychotic disorder diagnoses; male gender; no Medicaid insurance; and being African American. Patients older than 45, Medicaid beneficiaries, and those from Latino, Asian, and other non-Euro-American racial-ethnic groups were less likely to be incarcerated. Risk factors for reincarceration included co-occurring substance-related diagnoses; prior incarceration; diagnosed schizophrenia or bipolar disorder; homelessness; and incarceration for three or fewer days. Patients whose first service after release from incarceration was outpatient or case management were less likely to receive subsequent emergency services or to be reincarcerated within 90 days. CONCLUSIONS Modifiable factors affecting incarceration risk include homelessness, substance abuse, lack of medical insurance, and timely receipt of outpatient or case management services after release from incarceration.

Establishing an implementation network: lessons learned from community-based participatory research.

BackgroundImplementation of evidence-based mental health assessment and intervention in community public health practice is a high priority for multiple stakeholders. Academic-community partnerships can assist in the implementation of efficacious treatments in community settings; yet, little is known about the processes by which these collaborations are developed. In this paper, we discuss our application of community-based participatory research (CBPR) approach to implementation, and we present six lessons we have learned from the establishment of an academic-community partnership.MethodsWith older adults with psychosis as a focus, we have developed a partnership between a university research center and a public mental health service system based on CBPR. The long-term goal of the partnership is to collaboratively establish an evidence-based implementation network that is sustainable within the public mental healthcare system.ResultsIn building a sustainable partnership, we found that the following lessons were instrumental: changing attitudes; sharing staff; expecting obstacles and formalizing solutions; monitoring and evaluating; adapting and adjusting; and taking advantage of emerging opportunities. Some of these lessons were previously known principles that were modified as the result of the CBPR process, while some lessons derived directly from the interactive process of forming the partnership.ConclusionThe process of forming of academic-public partnerships is challenging and time consuming, yet crucial for the development and implementation of state-of-the-art approaches to assessment and interventions to improve the functioning and quality of life for persons with serious mental illnesses. These partnerships provide necessary organizational support to facilitate the implementation of clinical research findings in community practice benefiting consumers, researchers, and providers.

Patterns of Public Mental Health Service Use by Age in Patients With Schizophrenia

OBJECTIVE Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system. METHODS The study sample included 4,975 patients treated for schizophrenia in San Diego Countys Adult Mental Health Services (AMHS) during fiscal year 1999-2000. They compared three age-groups: 18-44 years (young adults), 45-64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management. RESULTS Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted. CONCLUSION Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups.

Posttraumatic stress disorder and health: a preliminary study of group differences in health and health behaviors

BackgroundIndividuals with posttraumatic stress disorder (PTSD) are more likely to undertake harmful health behaviors like substance use. Less is known about the association of PTSD with healthful behaviors such as healthy diet and exercise. The purpose of this study was to examine differences across physical health indicators and health behaviors in individuals with and without PTSD.MethodsA cross-sectional, case–control study of health indicators and self-reported health behaviors in a community and military veteran sample was used.ResultsBased on a structured psychiatric interview, 25 participants had PTSD, and the remaining 55 without PTSD served as the comparison group. Participants were 40 years old on average and 45% were female. Multivariate analysis of variance analyses revealed that participants with PTSD had significantly higher body mass index (p = 0.004), had more alcohol use (p = 0.007), and reported fewer minutes of vigorous exercise (p = 0.020) than those without PTSD. Chi-square analysis of diet content and eating behavior constructs found that individuals with PTSD ate fewer fruits (p = 0.035) and had more guilt after overeating (p = 0.006).ConclusionsThese findings replicate prior research on the link between PTSD and negative health outcomes and engagement in harmful health behaviors and highlight the need for further examination of the association between PTSD and other health behaviors like diet content, eating behaviors, and exercise.

Personality profiles among normal aged individuals as measured by the NEO-PI-R

Abstract The revised Neuroticism (N), Extraversion (E), Openness (O) to experience Personality Inventory (NEO-PI-R) is a multidimensional measure of normal personality traits that is intended to assess five major personality dimensions or domains—N, E, O, Agreeableness (A), and Conscientiousness (C). Although several studies have been conducted examining N; E, and O factors in people 65 through to 85 years old, there has been little research examining all five-core domains of personality in individuals 85 and older. We compared the NEO-PI-R domains and facet traits in the middle-aged/young-old versus old-old normal subjects. Thirty-eight community-dwelling subjects (22 women, 16 men) free from major neuropsychiatric disorders were given the NEO-PI-R, a self-administered 240-item personality inventory, assessing 30 facet traits within the five domains. We compared the scores of 21 middle-aged and young-old (age 50–84) individuals, to those of 17 old-old (age 85–100) subjects. The personality profiles of the two groups were similar except that the old-old group had lower scores on Extraversion, and four of the 30 facet traits (warmth, positive emotions, impulsiveness, and order) compared to the middle-aged/young-old group. These results were limited by the cross- sectional design and small sample size. Nonetheless, the findings suggest that the middle-aged/young-old and the old-old normal subjects have fairly similar personality traits.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia

OBJECTIVES This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

Public-Academic Partnerships: Improving Care for Older Persons With Schizophrenia Through an Academic-Community Partnership

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.