Barriers and Facilitators to Psychologists' Telepsychology Uptake during the Beginning of the COVID-19 Pandemic.

The COVID-19 pandemic transformed the delivery of psychological services as many psychologists adopted telepsychology for the first time or dramatically increased their use of it. The current study examined qualitative and quantitative data provided by 2619 practicing psychologists to identify variables facilitating and impeding the adoption of telepsychology in the U.S. at the beginning of the COVID-19 pandemic. The top five reported barriers were: inadequate access to technology, diminished therapeutic alliance, technological issues, diminished quality of delivered care or effectiveness, and privacy concerns. The top five reported facilitators were: increased safety, better access to patient care, patient demand, efficient use of time, and adequate technology for telepsychology use. Psychologists' demographic and practice characteristics robustly predicted their endorsement of telepsychology barriers and facilitators. These findings provide important context into the implementation of telepsychology at the beginning of the pandemic and may serve future implementation strategies in clinics and healthcare organizations attempting to increase telepsychology utilization.

Sex Specific Sleep Parameters Among People With Substance Use Disorder.

Introduction: Sleep can have substantial impacts in substance use disorder (SUD) pathogenesis, treatment, and recovery. Sex differences exist in both sleep and SUD, but how sleep is uniquely associated with SUD by sex is not known. The study objective was to compare, within sex, sleep parameters between individuals with SUD and non-substance misusing controls. Methods: Secondary analyses of a parent cross-sectional study examining the feasibility and acceptability of a novel neurocognitive phenotyping assessment battery were completed. SUD and control subjects were recruited through local advertising and an established research registry. Subjects with SUD were also recruited through a university-based outpatient SUD treatment clinic. Self-reported sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Sex-stratified t-tests compared sleep between SUD and control subjects while Crosstab analyses explored group differences in the proportion of individuals reporting poor sleep (defined as PSQI ≥ 5). Results: Data from 162 males (44 controls, 118 SUD) and 146 females (64 controls, 82 SUD) were included in the present study. For females only, a significantly lower proportion of controls reported PSQI-defined poor sleep than individuals with any SUD or specifically with opioid use disorder. Male, but not female, controls reported shorter sleep latency, longer sleep duration, and less sleep disturbance than males with each SUD type. Discussion/Implications: Sleep holds promise as an avenue to address SUD within a biopsychosocial model. Future work at the intersection of SUD and sleep should prioritize investigations of their interplay with sex to identify targets for tailored SUD interventions.

Insomnia Treatment Preferences Among Primary Care Patients.

PURPOSE: Sleep disturbance is common in primary care. The main treatment options include medication and cognitive behavioral therapy for insomnia. Best practice guidelines recommend a collaborative decision-making approach to treatment. This study examined differences in insomnia treatment preferences based on demographic and clinical characteristics among primary care patients. METHODS: A total of 200 patients (mean [SD] age, 54.92 [12.48] years) at a university medical center and community health clinic participated in brief screenings for insomnia, depression, anxiety, and insomnia treatment preference. Insomnia symptoms were measured with the Insomnia Severity Index, whereas depressive and anxiety symptoms were measured with the Patient Health Questionnaire 2 and Generalized Anxiety Disorder 2. χ2 analyses were performed to detect significant differences in preference between groups. FINDINGS: A total of 46.5% of participants preferred medication and 56.0% preferred behavioral treatment (ratings not exclusionary). Preference for behavioral treatment was highest among severe insomnia presentations (15.2% preferred to 4.5% disliked; P = 0.002). Medication preference was higher among patients with elevated anxiety (57.3% preferred to 42.7% disliked; P = 0.017). Preference for behavioral treatment (66.7% preferred to 33.3% disliked; P = 0.012) and medication (56.8% preferred to 43.2% disliked; P = 0.016) was highest among those with elevated depression. Treatment preference only differed by age for behavioral treatment (P = 0.008). Preference was highest among patients ≤51 years of age (67.2% preferred to 32.8% disliked). IMPLICATIONS: Primary care patients preferred behavioral and medication strategies for insomnia treatment. In addition, as mental health and sleep worsen, patients were more likely to prefer behavioral treatment. Knowledge of patient treatment preference may facilitate shared decision making, which increases patient satisfaction with care and engagement with treatment.

Insomnia symptoms during the COVID-19 pandemic: an examination of biopsychosocial moderators.

OBJECTIVE/BACKGROUND: Healthy sleep is vital for physical and psychological health, and poor sleep can result in a myriad of negative physical and psychological outcomes. Insomnia symptoms often manifest as a result of acute life stressors or changes, and COVID-19 experiences may be one such stressor. Other known predisposing factors to insomnia may moderate the impact of COVID-19 experiences on sleep. The present study aimed to determine current levels of insomnia severity in a US sample, to investigate the relation of COVID-19 experiences to insomnia symptoms, and to determine which individuals are most susceptible to this association. METHODS: Data were drawn from a larger online survey investigating sleep and health outcomes across the lifespan. COVID-19 experiences were assessed with the exposure and impact subscales of the CAIR Pandemic Impact Questionnaire (C-PIQ). The Insomnia Severity Index (ISI) measured insomnia symptoms. Biological, psychological, and social moderators were measured using other brief self-report measures. RESULTS: Insomnia symptoms prevalence was as follows: moderate-to-severe symptoms (25.5%), subthreshold symptoms (37.7%), and no symptoms (36.7%). Individuals' COVID-19 experiences significantly predicted insomnia symptom severity [F(1,997) = 472.92, p < 0.001, R2 = 0.32]. This association was moderated by race, anxiety symptoms, depressive symptoms, physical somatization, and social loneliness, but not age, gender, or education. CONCLUSIONS: Although negative experiences with COVID-19 are associated with worse insomnia symptoms, this relationship is not the same for everyone.

Exploration of Parkinson's Disease Symptomatology Subtypes From the Caregiver Perspective: Implications for Caregiver Burden, Depression, and Anxiety.

BACKGROUND: While research has demonstrated associations between Parkinson's disease (PD) severity and caregiver burden and emotional functioning, less is known about the associations between specific PD symptom patterns and caregiver functioning. OBJECTIVE: The purpose of the current study was to explore symptomatology subtypes in PD from the caregiver perspective in the U.S. and Mexico and to determine whether caregiver burden, depression, or anxiety differed by PD symptomatology subtype. METHODS: Two hundred fifty-three caregivers (M age = 59.9) completed Parts I and II of the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the Zarit Burden Interview, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scales. RESULTS: Cluster analysis using domains from the MDS-UPDRS revealed 5 symptomatology subtypes: pain/motor predominant, low symptoms, severe diffuse symptoms, moderate restricted symptoms with speech/oral predominant, and mood predominant. Caregiver burden was greatest for caregivers of individuals in the severe diffuse symptom and moderate restricted symptoms with speech/oral predominant clusters. High caregiver depression and caregiver anxiety were observed in all clusters other than the low symptoms cluster. There were no site by cluster interactions, suggesting that symptom patterns contribute to caregiver functioning in similar ways in the U.S. and Mexico. CONCLUSIONS: This data-driven analysis revealed 5 symptomatology subtypes of PD from caregivers' perspectives and highlighted the need for treatments and interventions based on predominant PD symptom expression. Importance of caregiver support across various symptomatology expressions, and particularly on specialist treatment for predominant speech/oral difficulties was recommended.

The Sleep Regularity Questionnaire: development and initial validation.

BACKGROUND/OBJECTIVE: Sleep is a critically important behavior which influences diverse aspects of health, functioning, and longevity. An increasing literature suggests the importance of sleep regularity, also referred to as sleep inconsistency, sleep variability, or intraindividual variability in sleep. Given there is no brief, subjective measure of sleep regularity, the purpose of this study was to develop the Sleep Regularity Questionnaire (SRQ) and to begin the process of examining its psychometric properties using a construct-validation approach. PARTICIPANTS/METHODS: In an online study of sleep and health, participants (n = 3249; Mage (SD) = 42.77 (16.73); 48.5% female; 77.3% white) completed the in-development SRQ, as well as the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. RESULTS: An exploratory factor analysis followed by a confirmatory factor analysis revealed a two factor structure, represented by circadian regularity and sleep continuity regularity, with good model fit indices (X2 = 50.9, df = 7, p < 0.001; RMSEA = 0.06; CFI = 0.99; NFI = 0.99; IFI = 0.99; TLI = 0.98). Test-retest reliability, as well as concurrent, convergent and incremental validity were examined, with promising results. CONCLUSIONS: Preliminary psychometrics suggest that the SRQ is a valid and stable instrument for the assessment of sleep regularity in adults that is related to, but distinct from, other established sleep constructs. Future research will benefit from assessing the validity of the SRQ in various clinical samples and how it compares to measures of sleep regularity calculated from prospective daily assessments.

Measurement of aggression in older adults.

Aggressive behaviors are prevalent in late-life and are associated with important consequences for older adults, caregivers, and healthcare providers. Age-related changes in the manifestation of aggression are precipitated in part by the rise of cognitive impairment. Such changes necessitate the use of psychometrically sound measures. The present article identifies existing measures of aggression for older adults, highlights the strengths and limitations of these measures, and proposes avenues for future research in this area. Five full-scale measures of aggression, as well as five subscales of aggression embedded within larger non-aggression measures in older adults were identified. Overall, measures of aggression specific to late-life are predominately observational and limited to individuals with dementia or older adults living in long-term care settings. The psychometric properties of aggression scales in late-life generally indicate adequate internal consistency, interrater reliability, and concurrent validity. In contrast, the reliability and validity of subscales of aggression contained within larger neuropsychiatric measures are more difficult to ascertain due to limited research. Future investigations would benefit from examining the psychometric properties of widely-used self-report measures of aggression among older adults, further evaluating the psychometric properties of aggression subscales, and developing additional measures which are predictive of aggressive behaviors.

Trading likes for sleepless nights: A lifespan investigation of social media and sleep.

OBJECTIVES: The present study sought to examine the association between social media use and sleep and whether the association differed by age. METHODS: Total 3,284 adults (M age = 42.74, SD = 16.72; 48.5% female; 80.8% White) participated in an online study of sleep and health across the lifespan. Sleep quality and duration were assessed using the Pittsburg Sleep Quality Index (PSQI). Participants reported the total time they spent using social media daily. RESULTS: Greater social media use was associated with poorer sleep quality (P < .001) and shorter sleep duration (P= .002). Age moderated the relationship between social media use and sleep quality (P= .006), as well as duration (P= .001). The strength of the associations between social media and sleep increased with age. CONCLUSION: The findings highlight potential adverse sleep outcomes associated with social media use. They also provide preliminary evidence suggesting the need for further exploration of age-related processes involved in social media use and sleep.

Examining models of psychologists' telepsychology use during the COVID-19 pandemic: A national cross-sectional study.

OBJECTIVE: The aim of this study is to apply the theory of reasoned action (TRA) and technology acceptance model (TAM) to psychologists' telepsychology use during the COVID-19 pandemic. METHODS: A sample of 2619 US-licensed psychologists completed a survey assessing telepsychology use and aspects of both models in May 2020. RESULTS: Cross-sectional TRA and TAM path models evidenced excellent fit in explaining psychologists' telepsychology use. The TRA indicated that psychologists' attitudes concerning telepsychology and subjective norms were associated with intentions to use telepsychology, which related to percentage of clinical work performed via telepsychology. The TAM showed that perceived usefulness of telepsychology and perceived ease of use were associated with attitudes toward telepsychology. Perceived usefulness was associated with psychologists' intention to use telepsychology, as was perceived ease of use. CONCLUSION: Efforts to facilitate telepsychology provision during the pandemic and broadly may benefit from trainings and campaigns to address attitudes toward telepsychology, subjective norms, and perceived ease of use.

A Placebo-Controlled, Pseudo-Randomized, Crossover Trial of Botanical Agents for Gulf War Illness: Curcumin (Curcuma longa), Boswellia (Boswellia serrata), and French Maritime Pine Bark (Pinus pinaster).

This report is part of a larger study designed to rapidly and efficiently screen potential treatments for Gulf War Illness (GWI) by testing nine different botanicals. In this placebo-controlled, pseudo-randomized, crossover clinical trial of 20 men with GWI, we tested three botanical agents with putative peripheral and central anti-inflammatory actions: curcumin (Curcuma longa), boswellia (Boswellia serrata), and French maritime pine bark extract (Pinus pinaster). Participants completed 30 +/- 3 days of baseline symptom reports, followed by 30 +/- 3 days of placebo, 30 +/- 3 days of lower-dose botanical, and 30 +/- 3 days of higher-dose botanical. Participants then repeated the process with a new botanical until completing up to three botanical cycles. Data were analyzed using linear mixed models. Curcumin reduced GWI symptom severity significantly more than placebo at both the lower (p < 0.0001) and higher (p = 0.0003) dosages. Boswellia was not more effective than placebo at reducing GWI symptoms at either the lower (p = 0.726) or higher (p = 0.869) dosages. Maritime pine was not more effective than placebo at the lower dosage (p = 0.954) but was more effective than placebo at the higher dosage (p = 0.006). This study provides preliminary evidence that curcumin and maritime pine may help alleviate symptoms of GWI. As a screening study, a final determination of the efficacy of these compounds for all individuals with GWI cannot be made, and further studies will need to be conducted to determine strength and durability of effects, as well as optimal dosage. These results suggest that GWI may, at least in part, involve systemic inflammatory processes. This trial was registered on ClinicalTrials.gov (NCT02909686) on 13 September 2016.

A Placebo-Controlled, Pseudo-Randomized, Crossover Trial of Botanical Agents for Gulf War Illness: Resveratrol (Polygonum cuspidatum), Luteolin, and Fisetin (Rhus succedanea).

A chronic multi-symptom illness of unknown etiology, Gulf War Illness (GWI) affects 175,000 to 250,000 veterans of the Gulf War. Because inflammation has suspected involvement in the pathophysiology of GWI, botanical treatments that target inflammation may be beneficial in reducing symptoms. No FDA-approved treatments currently exist for GWI, and rapid prioritization of agents for future efficacy testing is important. This study is part of a larger project that screened nine different botanical compounds with purported anti-inflammatory properties for potential treatment of GWI. We tested three botanicals (resveratrol [Polygonum cuspidatum], luteolin, and fisetin [Rhus succedanea]) on symptom severity of GWI in this placebo-controlled, pseudo-randomized clinical trial. Twenty-one male veterans with GWI completed the study protocol, which consisted of 1 month (30 days ± 3) of baseline symptom reports, 1 month of placebo, 1 month of lower-dose botanical, and 1 month of higher-dose botanical. Participants completed up to 3 different botanicals, repeating the placebo, lower-dose, and higher-dose cycle for each botanical assigned. Linear mixed models were used for analyses. Resveratrol reduced GWI symptom severity significantly more than placebo at both the lower (p = 0.035) and higher (p = 0.004) dosages. Luteolin did not decrease symptom severity more than placebo at either the lower (p = 0.718) or higher dosages (p = 0.492). Similarly, fisetin did not reduce symptom severity at either the lower (p = 0.504) or higher (p = 0.616) dosages. Preliminary findings from this screening study suggest that resveratrol may be beneficial in reducing symptoms of GWI and should be prioritized for future testing. Larger trials are required to determine efficacy, response rates, durability of effects, safety, and optimal dosage. This trial was registered on ClinicalTrials.gov (NCT02909686) on 13 September 2016.

A Placebo-Controlled, Pseudo-Randomized, Crossover Trial of Botanical Agents for Gulf War Illness: Reishi Mushroom (Ganoderma lucidum), Stinging Nettle (Urtica dioica), and Epimedium (Epimedium sagittatum).

This report is third in a three-part clinical trial series screening potential treatments for Gulf War Illness (GWI). The goal of the project was to rapidly identify agents to prioritize for further efficacy research. We used a placebo-controlled, pseudo-randomized, crossover design to test the effects of reishi mushroom (Ganoderma lucidum), stinging nettle (Uritca dioica), and epimedium (Epimedium sagittatum) in 29 men with GWI. Participants completed 30 days of symptom reports for baseline, then a botanical line consisting of 30 days of placebo, followed by 30 days each of lower-dose and higher-dose botanical. After completing a botanical line, participants were randomized to complete the protocol with another botanical, until they completed three botanical trials. GWI symptom severity, pain, and fatigue were contrasted between the four conditions (baseline, placebo, lower-dose, higher dose) using linear mixed models. GWI symptom severity was unchanged from placebo in the reishi lower-dose condition (p = 0.603), and was higher in the higher-dose condition (p = 0.012). Symptom severity was not decreased from placebo with lower-dose stinging nettle (p = 0.604), but was significantly decreased with higher-dose stinging nettle (p = 0.048). Epimedium showed no significant decreases of GWI symptoms in the lower (p = 0.936) or higher (p = 0.183) dose conditions. Stinging nettle, especially at higher daily dosages, may help reduce the symptoms of GWI. Epimedium does not appear to beneficially affect GWI symptom severity, and reishi may exaggerate symptoms in some GWI sufferers. These results are in a small sample and are preliminary. Further research is required to determine if stinging nettle is indeed helpful for the treatment of GWI, and what dosage is optimal. This trial was registered on ClinicalTrials.gov (NCT02909686).

Sleep Health as Measured by RU SATED: A Psychometric Evaluation.

Objective/Background: Sleep health is a multidimensional construct of sleep and wakefulness that operationalizes optimal sleep as more than the absence disease. Despite its importance to public health promotion efforts, empirical research examining sleep health is currently limited, possibly due to the lack of empirically validated measures. Therefore, the purpose of the current study was to evaluate the psychometric properties of a previously proposed six-item sleep health scale (RU- SATED). Participants: A sample of 3,401 adults (Mean Age = 42.77, 47.8% female) completed an online survey of sleep and health. Methods: Participants completed the RU-SATED scale, as well as other sleep-related measures including the Insomnia Severity Index (ISI) and the Sleep Self-Efficacy Scale (SSE). Results: An exploratory factor analysis (EFA) revealed a two-factor structure. A confirmatory factor analysis (CFA) using this two-factor structure demonstrated adequate to good model fit indices (X 2 = 45.96, df = 8, p < .01; RMSEA = .04; CFI = .98; NFI = .98; TLI = .97). Cronbach's α was .64 and the average interitem correlation was .22. RU-SATED was negatively associated with insomnia severity and positively associated with both self-reported sleep and sleep self-efficacy. Conclusions: RU-SATED appears to be a valid instrument for the assessment of sleep health among adults that is related to, but distinct from, other established sleep constructs. Future research may benefit from examining the test-retest reliability of the measure and assessing the predictive validity of sleep health as it relates to health-related outcomes.

Cognitive control beliefs and cognitive functioning in mid- to late-life.

OBJECTIVES: Older adults experience age-related cognitive declines and often feel as if the severity of these declines is out of their control. Recent research suggests, though, that control beliefs may be related to less age-related declines. The aim of the current study was to investigate cognitive domain-specific control beliefs and the link between those cognitive control beliefs and cognitive functioning among a nationwide sample of adults (N = 3,670), as well as to explore whether cognitive control beliefs moderated the relationship between age and cognitive functioning. METHOD: The aims were addressed using data from the national Midlife in the United States study (MIDUS II). Cognitive functioning was assessed using the Brief Test of Adult Cognition by Telephone (BTACT), and cognitive control beliefs were assessed with the Personality in Intellectual Aging Contexts (PIC) Inventory Control Scales. RESULTS: Regression analyses revealed that adults with higher control beliefs demonstrated better cognitive functioning. Moderation analyses indicated cognitive control beliefs moderated the relationship between age and executive functioning, but not the association between age and episodic memory. CONCLUSION: Results suggested that the relationship between age and executive functioning was weaker at high levels of cognitive control beliefs. Future research should establish the directionality of the effect between cognitive control beliefs and cognition and investigate the association between control beliefs and cognition in samples at higher risk for substantial cognitive decline, including the oldest-old.

Sleep Inconsistency and Markers of Inflammation.

Objective: Poor sleep is associated with higher levels of inflammatory biomarkers. Conventionally, higher average time awake, lower average time asleep, and lower sleep efficiency define poor sleep. Recent research suggests that, in addition to average sleep, sleep inconsistency is an important indicator of sleep dysfunction. The current study sought to extend our knowledge of the relationship between sleep and inflammation through an examination of sleep inconsistency and inflammatory biomarkers. Methods: Secondary analyses of the Survey of Midlife in the United States (MIDUS) sleep study were conducted. Five hundred thirty-three individuals completed nightly sleep diaries, actigraphy, and underwent a blood draw for the inflammatory biomarkers C-reactive protein, interleukin-6, and fibrinogen. Sleep inconsistency was derived from 7 consecutive nights of assessment and was operationalized as nightly fluctuations in the following variables: terminal wakefulness, number of awakenings, time in bed, sleep onset latency, and wake after sleep onset. Structural equation modeling was used to examine the influence of a latent average sleep and a latent sleep inconsistency variable on a latent inflammation variable. Models were subsequently adjusted for age, sex, BMI, health, and medication. Stratified models by sex were also analyzed. Results: The average sleep model would not converge. The sleep inconsistency model fit the data well. A significant positive association between the latent factors sleep inconsistency and inflammation was observed (ß = 10.18, SE = 4.40, p = 0.021), suggesting inconsistent sleep is associated with higher levels of inflammatory biomarkers. When stratified by sex, the association between the latent sleep inconsistency factor and inflammation was significant for women (ß = 1.93, SE = 0.82, p = 0.018), but not men (ß = 0.20, SE = 0.35, p = 0.566). The association between sleep inconsistency and inflammation weakened following multivariate adjustment (ß = 6.23, SE = 3.71, p = 0.093). Conclusions: Inconsistent sleep may be an associated feature of inflammatory dysfunction, especially in women. Future studies should build upon this preliminary work and examine these associations longitudinally and through treatment trials.

Parkinson's family dynamics and caregiver sense of coherence: A family-systems approach to coping in Mexico and the United States.

OBJECTIVE: The population of individuals with Parkinson's disease (PD) is growing in Mexico and the United States, and there is an increasing need for family members to provide caregiving. This study examined the connections between family dynamics and coping, or sense of coherence, among PD caregivers in Mexico (n = 148) and the United States (n = 105). METHODS: Caregivers completed measures of family dynamics and sense of coherence across indices of comprehensibility, manageability, and meaningfulness. RESULTS: Although caregivers in Mexico and the United States had similar levels of sense of coherence and family dynamics reflecting strengths/adaptability and being overwhelmed with difficulties, caregivers in Mexico had worse disrupted communication. Family dynamics explained: 24.2% of the variance in caregiver comprehensibility in the United States and 17.5% in Mexico; 34.1% in manageability in the United States and 23.5% in Mexico; and 22.6% in meaningfulness in the United States and 22.7% in Mexico (all Ps < 0.001). In both Mexico and the United States, family strengths/adaptability uniquely predicted caregiver comprehensibility, manageability, and meaningfulness. Being overwhelmed with difficulties uniquely predicted comprehensibility in Mexico and manageability and meaningfulness in the United States. CONCLUSION: The development of family-systems interventions for PD caregivers to improve family strengths/adaptability and help families deal with difficulties may increase caregiver coping.

Parkinson's family needs and caregiver mental health: A cross-cultural comparison between Mexico and the United States.

BACKGROUND/OBJECTIVE: Given the growing population of individuals with Parkinson's disease (PD) worldwide and the growing need for family members to take on a caregiving role, it is critical that cross-cultural differences be examined in order to better meet the needs of PD caregivers. The purpose of this study was to examine the connections between the unmet needs and mental health of PD caregivers differentially in Mexico and the United States. METHODS: In Parkinson's clinics at public, academic medical centers, PD caregivers from Mexico (n = 148) and the United States (n = 105) completed measures of unmet family needs and mental health. RESULTS: Caregivers in the United States had higher unmet needs for emotional support and for a community support network than caregivers in Mexico, although caregivers at the two sites had comparable levels of anxiety and depression. Unmet family needs explained 29.5% of the variance in caregiver anxiety in the United States (p < 0.001) but only 5.7% in Mexico (p = 0.209). Unmet family needs explained 30.4% of the variance in caregiver depression in the United States (p < 0.001) and 14.0% in Mexico (p = 0.001). In the United States, unmet needs for emotional support and for instrumental support uniquely predicted caregiver anxiety and depression, and in Mexico only the unmet need for instrumental support was a unique predictor. CONCLUSIONS: PD caregivers in the United States are at increased risk for poor emotional and community support, and these unmet needs channel directly into caregiver anxiety and depression. In Mexico, where caregivers have stronger emotional and community support, caregivers' unmet need for instrumental support generates anxiety and depression. Important targets for PD caregiver interventions may differ between Mexico and the United States.