Paul Michael Ramirez

Focus on geriatric psychiatry: schizophrenia in later life: clinical symptoms and social well-being.

The number of persons aged 55 and older with a diagnosis of schizophrenia is projected to double over the next 20 years. A tripartite classification system of early-onset schizophrenia, late-onset schizophrenia, and very-late-onset schizophrenia-like psychosis has been proposed. This column reviews recent findings on the outcome and associated features of clinical symptom and social well-being categories for older adults with early-onset schizophrenia.

KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia

OBJECTIVE Tardive dyskinesia is a persistent movement disorder induced by dopamine receptor blockers, including antipsychotics. Valbenazine (NBI-98854) is a novel, highly selective vesicular monoamine transporter 2 inhibitor that demonstrated favorable efficacy and tolerability in the treatment of tardive dyskinesia in phase 2 studies. This phase 3 study further evaluated the efficacy, safety, and tolerability of valbenazine as a treatment for tardive dyskinesia. METHOD This 6-week, randomized, double-blind, placebo-controlled trial included patients with schizophrenia, schizoaffective disorder, or a mood disorder who had moderate or severe tardive dyskinesia. Participants were randomly assigned in a 1:1:1 ratio to once-daily placebo, valbenazine at 40 mg/day, or valbenazine at 80 mg/day. The primary efficacy endpoint was change from baseline to week 6 in the 80 mg/day group compared with the placebo group on the Abnormal Involuntary Movement Scale (AIMS) dyskinesia score (items 1-7), as assessed by blinded central AIMS video raters. Safety assessments included adverse event monitoring, laboratory tests, ECG, and psychiatric measures. RESULTS The intent-to-treat population included 225 participants, of whom 205 completed the study. Approximately 65% of participants had schizophrenia or schizoaffective disorder, and 85.5% were receiving concomitant antipsychotics. Least squares mean change from baseline to week 6 in AIMS dyskinesia score was -3.2 for the 80 mg/day group, compared with -0.1 for the placebo group, a significant difference. AIMS dyskinesia score was also reduced in the 40 mg/day group (-1.9 compared with -0.1). The incidence of adverse events was consistent with previous studies. CONCLUSIONS Once-daily valbenazine significantly improved tardive dyskinesia in participants with underlying schizophrenia, schizoaffective disorder, or mood disorder. Valbenazine was generally well tolerated, and psychiatric status remained stable. Longer trials are necessary to understand the long-term effects of valbenazine in patients with tardive dyskinesia.

An Object Lesson: Source Determines the Relations That Trait Anxiety, Prostate Cancer Worry, and Screening Fear Hold with Prostate Screening Frequency

Fears regarding prostate cancer and the associated screening are widespread. However, the relations between anxiety, cancer worry, and screening fear and screening behavior are complex, because anxieties stemming from different sources have different effects on behavior. In differentiating among anxieties from different sources (trait anxiety, cancer worry, and screening fear), we expected that cancer worry would be associated with more frequent screening, whereas fear of screening would be associated with less frequent screening. Hypotheses were tested in a sample of 533 men (ages 45-70 years) recruited using a stratified cluster-sampling plan. Men provided information on demographic and structural variables (age, education, income, marital status, physician discussion of risk and screening, access, and insurance) and completed a set of anxiety measures (trait anxiety, cancer worry, and screening fear). As expected, two-step multiple regressions controlling for demographics, health insurance status, physician discussion, and health-care system barriers showed that prostate-specific antigen and digital rectal examination frequencies had unique associations with cancer worry and screening fear. Specifically, whereas cancer worry was associated with more frequent screening, fear of screening was associated with less frequent screening at least for digital rectal examination; trait anxiety was inconsistently related to screening. Data are discussed in terms of their implications for male screening and the understanding of how anxiety motivates health behaviors. It is suggested that understanding the source of anxiety and the manner in which health behaviors such as cancer screenings may enhance or reduce felt anxiety is a likely key to understanding the associations between anxiety and behavioral outcomes. (Cancer Epidemiol Biomarkers Prev 2008;17(7):1631–9)

Fear, knowledge, and efficacy beliefs differentially predict the frequency of digital rectal examination versus prostate specific antigen screening in ethnically diverse samples of older men.

Emotional and cognitive characteristics have been studied in the context of women’s cancer screening but have received scant attention in the study of men’s screening behavior. Researchers know little about how such factors interact to predict screening or whether digital rectal examination (DRE) and prostate specific antigen (PSA) screens are predicted by the same characteristics. This study examines the relevance of emotional and cognitive characteristics to DRE and PSA screening among 180 U.S.-born African American, U.S.- born European American, and immigrant Jamaican men. The study identifies the expected effects in which fear is negatively related and efficacy beliefs positively related to DRE and PSA screening. Greater efficacy and (marginally) knowledge appear to “offset” the negative impact of fear on screening, and fear appears particularly relevant to DRE frequency. Results are discussed in terms of their implications for the development of health belief and self-regulatory models in the context of prostate cancer screening among minority men.

Adequacy of Medical Treatment Among Older Persons With Schizophrenia

OBJECTIVE This study used Krauses model of illness behavior in later life to examine factors associated with adequacy of medical treatment in a racially diverse sample of older patients (age 55 and over) with schizophrenia. METHODS In a cross-sectional community study, 119 persons were identified from a sample of 198 persons with schizophrenia age 55 or older who developed the disorder before age 45; for comparison, 57 persons were identified from a group of 113 without the disorder. The groups were compared for treatment of one or more of four common medical disorders. Thirteen independent variables were inserted into Krauses model for the comparisons. A dependent variable was created to indicate whether persons received medication treatment for all of their medical disorders (high-treatment group). RESULTS Significant differences were found between the schizophrenia and control groups in the proportion receiving treatment for the four physical conditions (.61 versus .83, respectively, p=.004). By logistic regression, four of 13 variables for the schizophrenia group were significantly associated (p<.01) with being in the high-treatment group: absence of depression, lower frequency of medical visits, fewer positive symptoms, and more negative symptoms. CONCLUSIONS Although older patients with schizophrenia and their age peers had similar levels of physical disorders and rates of health visits, the former received less adequate treatment. More aggressive management of comorbid depression and positive symptoms of schizophrenia may help in improving the health of this population.

Successful Aging in Older Adults With Schizophrenia: Prevalence and Associated Factors

OBJECTIVE This study contrasts the prevalence of successful aging in older adults with schizophrenia with their age peers in the community and examines variables associated with successful aging in the schizophrenia group. METHODS The schizophrenia group consisted of 198 community-dwelling persons aged 55 years and older who developed schizophrenia before the age of 45 years. A community comparison group (N = 113) was recruited using randomly selected block groups. The three objective criteria proposed by Rowe and Kahn were operationalized using a six-item summed score. The association of 16 predictor variables with the successful aging score in the schizophrenia group was examined. RESULTS The community group had significantly higher successful aging scores than the schizophrenia group (4.3 versus 3.0; t = 8.36, df = 309, p <0.001). Nineteen percent of the community group met all six criteria on the successful aging score versus 2% of the schizophrenia group. In regression analysis, only two variables-fewer negative symptoms and a higher quality of life index-were associated with the successful aging score within the schizophrenia group. CONCLUSION Older adults with schizophrenia rarely achieve successful aging and do so much less commonly than their age peers. Only two significant variables were associated with successful aging neither of which are easily remediable. The elements that comprise the components of successful aging, especially physical health, may be better targets for intervention.

EEG Biofeedback Treatment of ADD

Abstract: Literature searches dating back to 1968 were conducted through Psychlit and Medline services to review the scientific literature on EEG biofeedback treatment of ADD. While anecdotal and case reports cite promising evidence, methodological problems coupled with a paucity of research precludes any definitive conclusions as to the efficacy of enhanced alpha and hemisphere‐specific EEG biofeedback training. One of the more promising EEG biofeedback treatment paradigms involves theta/beta training. Studies have reported that academic, intellectual, and behavioral gains have been attained with this approach. Significant behavioral and cognitive changes have also been reported following SMR training. However, research into these treatment approaches has also been marred by methodological inadequacies and lack of sufficient follow‐up studies. A number of recommendations for future research into this treatment approach are made.

Symptomatic Remission in a Multiracial Urban Population of Older Adults with Schizophrenia

OBJECTIVE Symptomatic remission has been reported in younger patients with schizophrenia. This study aims to determine the prevalence of symptomatic remission in older adults with schizophrenia. METHODS The Schizophrenia Group consisted of 198 persons aged 55+ years living in the community who developed schizophrenia before age 45 years. Our definition of remission was adapted from the criteria of the Remission in Schizophrenia Working Group. To attain remission, persons had to have scores of <3 on eight domains of the Positive and Negative Symptom Scale and no hospitalizations within the previous year. Using Georges Social Antecedent Model, we examined the association of remission with 18 predictor variables. RESULTS Forty-nine percent of the sample met the criteria for symptomatic remission. In logistic regression analysis, four variables--fewer total network contacts, greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores--were significantly associated with remission. CONCLUSIONS Remission rates were consistent with those reported in younger samples. Our findings suggest that symptomatic remission is an attainable goal and that treatments focused on those variables associated with remission may augment outcomes in older persons with schizophrenia.

Subjective reasons for adherence to psychotropic medication and associated factors among older adults with schizophrenia

RATIONALE There are limited data examining subjective influences on medication adherence among older persons with schizophrenia. The subjective reasons for adherence to antipsychotic medication and associated clinical and psychosocial factors in this population are examined. METHODS The sample consisted of 198 community dwelling persons aged >or=55 who developed schizophrenia before age 45. Using the Rating of Medication Influences Scale (ROMI), a principal component factor analysis with varimax rotation yielded three subscales: Medication Affinity and Prevention, Influence of Others, and Impact of Authority. These subscales were dichotomized into high and low based on a median split. We also created an ordinal High Adherence measure based on the summed scores of each persons three dichotomized ROMI subscales. A modified Health Belief Model was used to examine the association between 18 predictor variables and the ROMI subscales and the adherence scale. RESULTS The mean subscale rankings were Medication Affinity and Prevention > Impact of Authority > Influence of Others. In logistic regression, lower education, more side effects, higher depression scores, and more mental health services were associated with higher scores on Influence of Others subscale. More side effects and more entitlements were associated with higher scores on the Medication Affinity and Prevention subscale. The Impact of Authority subscale had no significant associations. More side effects and higher depression scores were associated with higher scores on High Adherence measure. CONCLUSION We identified a three-dimensional model for explaining the subjective reasons for medication adherence in older persons with schizophrenia. Our findings suggest that cognitive approaches and use of authority figures may be useful for promoting adherence in older adults. Independent variables associated with these subscales may provide guidance for improving adherence in this population.

Examining the role of trauma, personality, and meaning in young prolonged grievers

Younger spouses or partners have been understudied in the prolonged grief literature. The purpose of this study was to determine rates of prolonged grief in young spouses or partners and the associations between prolonged grief and personality styles (specifically, narcissistic, histrionic, and obsessive), trauma history, and the perceived meaning of the loss in the young conjugally bereaved.