The house is a machine for everything: the role of the built environment in group homes during the COVID-19 pandemic.

OBJECTIVES: Individuals living in group homes during the COVID-19 pandemic faced unique challenges and health risks related to living in shared spaces. This study aimed to assess the experiences of living and working in a group home during the pandemic and to explore the role of the built environment. STUDY DESIGN AND METHODS: We conducted longitudinal working groups with group home residents with intellectual and developmental disabilities and serious mental illness, group home staff, and families/caregivers of residents from December 2020 through December 2022. Common themes highlighting ways in which group home residents, staff, and caregivers perceived the built environment to impact living in a group home during the COVID-19 pandemic were identified. RESULTS: Resonant themes centered around increased risk of COVID-19 infection, ad hoc spatial adaptations for infection control, space-related challenges due to isolation and quarantine requirements, and limited access to public spaces. CONCLUSION: Group home residents and staff experienced multiple health and wellness challenges during the COVID-19 pandemic related to their surrounding built environment. Mechanisms to engage group home residents in modifications of their built environment may improve the effectiveness of infection control policies while acknowledging individual autonomy.

Association of adiposity, telomere length and mortality: data from the NHANES 1999-2002.

BACKGROUND/OBJECTIVES: Telomere shortening is associated with age and risk of medical comorbidity. We assessed the relationship between measures of adiposity, leukocyte telomere length, and mortality and whether it is modified by age. SUBJECTS/METHODS: Subjects with dual-energy X-ray absorptiometry measures were identified using the National Health and Nutrition Examination Survey 1999-2002. Obesity was categorized using two body fat definitions (BF1%: men ⩾25%; females ⩾35%; BF2% ⩾28% and ⩾38%, respectively), body mass index (BMI) and waist circumference (WC; men ⩾102 cm; females ⩾88 cm). Telomere length relative to standard reference DNA (T/S ratio) was assessed using quantitative PCR. Weighted multivariable regression models evaluated the association of telomere length with adiposity, both continuously and categorically (low/normal BF%, low/high WC and standard BMI categories). Differences in telomere length by age and adiposity were ascertained and subsequent models were stratified by age. Proportional hazard models assessed the risk of mortality by adiposity status. A telomere by adiposity interaction was tested in the entire cohort and by age category (<60 vs ⩾60 years; <70 vs ⩾70 years). RESULTS: We identified 7827 subjects. Mean age was 46.1 years. Overall telomere length was 1.05±0.01 (s.e.) that differed by BF1% (low/high: 1.12±0.02 vs 1.03±0.02; P<0.001), BF2% (1.02±0.02 vs 1.11±0.02; P<0.001), BMI (underweight 1.08±0.03; normal 1.09±0.02; overweight 1.04±0.02; and obese 1.03±0.02;P<0.001) and WC (low/high 1.09±0.02 vs 1.02±0.02; P<0.001). Adjusted ß-coefficients evaluating the relationship between telomere length and adiposity (measured continuously) were as follows: BF1% (ß=-0.0033±0.0008; P<0.001), BF2% (-0.041±0.008; P<0.001), BMI (ß=-0.025±0.0008; P=0.005) and WC (ß=-0.0011±0.0004; P=0.007). High BF% (BF1%: ß=-0.035±0.011; P=0.002; BF2%: ß=-0.041±0.008; P<0.001) and WC (ß=-0.035±0.011; P=0.008) were inversely related to telomere length (TL). Stratifying by age, high BF1% (-0.061±0.013), BF2% (-0.065±0.01), BMI-obesity (-0.07±0.015) and high WC (-0.048±0.013) were significant (all P<0.001). This association diminished with increasing age. In older participants, TL was inversely related to mortality (hazard ratio 0.36 (0.27, 0.49)), as were those classified by BF1% (0.68 (0.56, 0.81)), BF2% (0.75 (0.65, 0.80)), BMI (0.50 (0.42, 0.60)) and WC (0.72 (0.63, 0.83)). No interaction was observed between adiposity status, telomere length and mortality. CONCLUSIONS: Obesity is associated with shorter telomere length in young participants, a relationship that diminishes with increasing age. It does not moderate the relationship with mortality.

Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999-2004.

BACKGROUND: Body composition changes with aging lead to increased adiposity and decreased muscle mass, making the diagnosis of obesity challenging. Conventional anthropometry, including body mass index (BMI), while easy to use clinically may misrepresent adiposity. We determined the diagnostic accuracy of BMI using dual-energy X-ray absorptiometry (DEXA) in assessing the degree of obesity in older adults. METHODS: The National Health and Nutrition Examination Surveys 1999-2004 were used to identify adults aged ⩾60 years with DEXA measures. They were categorized (yes/no) as having elevated body fat by gender (men: ⩾25%; women ⩾35%) and by BMI ⩾25 and ⩾30 kg m(-)(2). The diagnostic performance of BMI was assessed. Metabolic characteristics were compared in discordant cases of BMI/body fat. Weighting and analyses were performed per NHANES (National Health and Nutrition Examination Survey) guidelines. RESULTS: We identified 4984 subjects (men: 2453; women: 2531). Mean BMI and % body fat was 28.0 kg m(-2) and 30.8% in men, and 28.5 kg m(-)(2) and 42.1% in women. A BMI ⩾30 kg m(-)(2) had a low sensitivity and moderately high specificity (men: 32.9 and 80.8%, concordance index 0.66; women: 38.5 and 78.5%, concordance 0.69) correctly classifying 41.0 and 45.1% of obese subjects. A BMI ⩾25 kg m(-2) had a moderately high sensitivity and specificity (men: 80.7 and 99.6%, concordance 0.81; women: 76.9 and 98.8%, concordance 0.84) correctly classifying 80.8 and 78.5% of obese subjects. In subjects with BMI <30 kg m(-)(2), body fat was considered elevated in 67.1% and 61.5% of men and women, respectively. For a BMI ⩾30 kg m(-)(2), sensitivity drops from 40.3% to 14.5% and 44.5% to 23.4%, whereas specificity remains elevated (>98%), in men and women, respectively, in those 60-69.9 years to subjects aged ⩾80 years. Correct classification of obesity using a cutoff of 30 kg m(-)(2) drops from 48.1 to 23.9% and 49.0 to 19.6%, in men and women in these two age groups. CONCLUSIONS: Traditional measures poorly identify obesity in the elderly. In older adults, BMI may be a suboptimal marker for adiposity.

Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative.

OBJECTIVES: Older adults with obesity are at risk for osteoarthritis (OA) and are predisposed to functional decline and disability. We examined the association between obesity and disability, physical activity, and quality of life at 6 years. METHOD: Using data from the longitudinal Osteoarthritis Initiative (OAI), we analysed older adults (age ≥ 60 years) with a body mass index (BMI) at baseline ≥ 18.5 kg/m(2) (n = 2378) using standard BMI categories. Outcomes were assessed at the 6-year follow-up and included: the Late-Life Function and Disability Index (LLDI), the 12-item Short Form Health Survey (SF-12), and the Physical Activity Scale for the Elderly (PASE). Linear regression predicted outcomes based on BMI category, adjusting for age, sex, race, education, smoking, cohort status, radiographic knee OA, co-morbidity scores, and baseline scores when available. RESULTS: Follow-up data were available for 1727 (71.9%) participants (mean age 67.9 ± 5.3 years; 61.6% female). At baseline, obese subjects compared to overweight and normal were on a greater number of medications (4.28 vs. 3.63 vs. 3.32), had lower gait speeds (1.22 vs. 1.32 vs. 1.36 m/s), higher Charlson scores (0.59 vs. 0.37 vs. 0.30), and higher Western Ontario and McMaster University OA Index (WOMAC) scores (right: 14.8 vs. 10.3 vs. 7.5; left: 14.4 vs. 9.9 vs. 7.5). SF-12 scores at 6 years were lower in obese patients than in overweight or normal [99.5 (95% CI 98.7-100.4) vs. 101.1 (95% CI 100.4-101.8) vs. 102.8 (95% CI 101.8-103.8)], as were PASE scores [115.1 (95% CI 110.3-119.8) vs. 126.2 (95% CI 122.2-130.2) vs. 131.4 (95% CI 125.8-137.0)]. The LLDI limitation component demonstrated differences in obese compared to overweight or normal [78.6 (95% CI 77.4-79.9) vs. 81.2 (95% CI 80.2-82.3) vs. 82.5 (95% CI 81.1-84.0)]. CONCLUSIONS: Obesity was associated with worse physical activity scores, lower quality of life, and higher risk of 6-year disability.

Association of Obesity and Frailty in Older Adults: NHANES 1999-2004.

OBJECTIVES: Body composition changes with aging can increase rates of obesity, frailty and impact function. Measuring adiposity using body fat (%BF) or central adiposity using waist circumference (WC) have greater diagnostic accuracy than traditional measures such as body mass index (BMI). DESIGN: This is an observational study. SETTING: This study focused on older community-dwelling participants. PARTICIPANTS: We identified individuals age ≥ 60 years old using the 1999-2004 cross-sectional National Health and Nutrition Survey (NHANES). INTERVENTION: The primary analysis evaluated the association between frailty and %BF or WC. Frailty was the primary predictor (robust=referent) and %BF and WC were considered continuous outcomes. Multiple imputation analyses accounted for missing characteristics. MEASUREMENT: Dual energy x-ray absorptiometry was used to assess %BF and WC was objectively measured. Frailty was defined using an adapted version of Fried's criteria that was self-reported: (low BMI<18.5kg/m2; slow walking speed [<0.8m/s]; weakness [unable to lift 10lbs]; exhaustion [difficulty walking between rooms on same floor] and low physical activity [compared to others]). Robust, pre-frail and frail persons met zero, 1 or 2, and ≥3 criteria, respectively. RESULTS: Of the 4,984 participants, the mean age was 71.1±0.2 (SE) years and 56.5% were females. We classified 2,246 (50.4%), 2,195 (40.3%), and 541 (9.2%) individuals as robust, pre-frail and frail, respectively. Percent BF was 35.9±0.13, 38.3±0.20 and 40.0±0.46 in the robust, pre-frail and frail individuals, respectively. WC was 99.5±0.32 in the robust, 100.1±0.43 in pre-frail, 104.7±1.17 in frail individuals. Compared to robust individuals, only frail individuals had greater %BF on average (ß=0.97±0.43,p=0.03); however, pre-frail and frail individuals had 2.18 and 4.80 greater WC, respectively (ß=2.18±0.64,p=0.002, and ß=4.80±1.1,p<0.001). CONCLUSION: Our results demonstrate that in older adults, frailty and pre-frailty are associated with a greater likelihood of high WC (as dichotomized) and a greater average WC (continuous).

Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011-2014.

OBJECTIVES: Sarcopenia is a gradual loss of muscle mass and strength that occurs with aging. This muscle deterioration is linked to increased morbidity, disability, and other adverse outcomes. Although reduced handgrip strength can be considered a marker of sarcopenia and other aging-related decline in the elderly, there is limited research on this physical health problem in at-risk groups with common biopsychosocial conditions such as depression. Our primary objective was to ascertain level of combined handgrip strength and its relationship with depression among adults aged 60 years and older. DESIGN: Unadjusted and adjusted linear regression models were conducted with a cross-sectional survey dataset. SETTING: Secondary dataset from the 2011-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: Community-dwelling, non-institutionalized adults ≥60 years old (n=3,421). MEASUREMENTS: The predictor variables included a positive screen for clinically relevant depression (referent=PHQ-9 score <10). The criterion variable of combined handgrip strength (kg) was determined using a dynamometer. RESULTS: Mean age and BMI were 69.9 years (51.5% female) and 28.8 kg/m2, respectively. Mean combined handgrip strength in the overall cohort was 73.5 and 46.6 kg in males and females, respectively. Three hundred thirty-six (9.8%) reported symptoms of depression. In unadjusted and fully adjusted models, depression was significantly associated with reduced handgrip strength (B = -0.26±0.79 and B = -0.19±0.08, respectively; p<0.001). CONCLUSION: Our findings demonstrate handgrip strength has a significant inverse association with depression. Future longitudinal studies should investigate the causal processes and potential moderators and mediators of the relationships between depression and reduced handgrip strength. This information may further encourage the use of depression and handgrip strength assessments and aid in the monitoring and implementation of health care services that address both physical and mental health limitations among older adult populations.

Prevalence of weakness and its relationship with limitations based on the Foundations for the National Institutes for Health project: data from the Health and Retirement Study.

BACKGROUND/OBJECTIVES: The objectives of this study were to determine the prevalence of muscle weakness using the two 2014 Foundation for the National Institutes of Health (FNIH) Sarcopenia Project criteria and its relationship with physical limitations, basic activities of daily living (ADL) and instrumental ADL. SUBJECTS/METHODS: We performed a cross-sectional analysis of community-dwelling adults from the Health and Retirement Study 2006-2008 and identified a subsample of 5092 adults aged ⩾60 years with grip strength (GS) data. Self-reported physical limitations, basic ADL and instrumental ADL were assessed. Criteria for GS (men<26 kg; women <16 kg) and GS adjusted for body mass index (GS/BMI; men <1.0; women <0.56) were applied to the sample. We determined the prevalence of muscle weakness in each sex. Multivariable logistic regression was used to calculate the association of physical limitations, basic ADL and instrument ADL with weakness definitions in each sex. RESULTS: Mean age was 72.1 years (54.9% female). Mean GS was 38.3 and 22.9 kg and mean BMI was 29 kg/m2, respectively, in men and women. Weakness prevalence using GS and GS:BMI definitions were 7.8 and 15.2 (P<0.001), respectively, in men and 11.4 and 13.3% (P=0.04) in women. Overall prevalence of physical limitations, basic ADL limitations and instrumental ADL limitations was 52.9, 28.1 and 35.9%, respectively. In those with weakness, prevalence of physical limitations, basic ADL and instrumental ADL was 78.5, 42.3 and 65.3%, respectively, using the GS definition, and 79.7, 40.7 and 58.8%, respectively, using the GS/BMI definition. GS and the GS/BMI definitions of weakness were strongly associated with physical limitations (odds ratio (OR) 2.19 (95% confidence interval (CI): (1.67-2.87)) and 2.52 (2.01-3.17)), basic ADL (OR 1.59 (1.22-2.07) and 1.66 (1.32-2.07)) and instrumental ADLs (OR 1.98 (1.28-2.54) and 1.78 (1.44-2.20)). CONCLUSIONS: The new FNIH guidelines for weakness are associated with higher prevalence of physical limitations, basic ADL impairments and instrumental ADL impairments as compared with individuals without weakness.

The future of mental health care: peer-to-peer support and social media.

AIMS: People with serious mental illness are increasingly turning to popular social media, including Facebook, Twitter or YouTube, to share their illness experiences or seek advice from others with similar health conditions. This emerging form of unsolicited communication among self-forming online communities of patients and individuals with diverse health concerns is referred to as peer-to-peer support. We offer a perspective on how online peer-to-peer connections among people with serious mental illness could advance efforts to promote mental and physical wellbeing in this group. METHODS: In this commentary, we take the perspective that when an individual with serious mental illness decides to connect with similar others online it represents a critical point in their illness experience. We propose a conceptual model to illustrate how online peer-to-peer connections may afford opportunities for individuals with serious mental illness to challenge stigma, increase consumer activation and access online interventions for mental and physical wellbeing. RESULTS: People with serious mental illness report benefits from interacting with peers online from greater social connectedness, feelings of group belonging and by sharing personal stories and strategies for coping with day-to-day challenges of living with a mental illness. Within online communities, individuals with serious mental illness could challenge stigma through personal empowerment and providing hope. By learning from peers online, these individuals may gain insight about important health care decisions, which could promote mental health care seeking behaviours. These individuals could also access interventions for mental and physical wellbeing delivered through social media that could incorporate mutual support between peers, help promote treatment engagement and reach a wider demographic. Unforeseen risks may include exposure to misleading information, facing hostile or derogatory comments from others, or feeling more uncertain about one's health condition. However, given the evidence to date, the benefits of online peer-to-peer support appear to outweigh the potential risks. CONCLUSION: Future research must explore these opportunities to support and empower people with serious mental illness through online peer networks while carefully considering potential risks that may arise from online peer-to-peer interactions. Efforts will also need to address methodological challenges in the form of evaluating interventions delivered through social media and collecting objective mental and physical health outcome measures online. A key challenge will be to determine whether skills learned from peers in online networks translate into tangible and meaningful improvements in recovery, employment, or mental and physical wellbeing in the offline world.

Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades.

It is anticipated that the number of people older than 65 years with psychiatric disorders in the United States will increase from about 4 million in 1970 to15 million in 2030. The current health care system serves mentally ill older adults poorly and is unprepared to meet the upcoming crisis in geriatric mental health. We recommend the formulation of a 15- to 25-year plan for research on mental disorders in elderly persons. It should include studies of prevention, translation of findings from bench to bedside, large-scale intervention trials with meaningful outcome measures, and health services research. Innovative strategies are needed to formulate new conceptualizations of psychiatric disorders, especially those given scant attention in the past. New methods of clinical and research training involving specialists, primary care clinicians, and the lay public are warranted.

Alcohol abuse, depression, and suicidal behavior in schizophrenia.

Alcohol use was correlated with depression and suicidal behavior in two independent studies of schizophrenic outpatients. Depression alone accounted for over 80% of the explained variance in suicidal behavior in both studies; alcohol use alone and the correlation between depression and alcohol use accounted for only small amounts of variance.

A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community.

This study compared the functioning of 188 elderly schizophrenic and bipolar disorder patients living in nursing homes and the community. Residential status and diagnostic groups were compared on measures of symptomatology, cognitive impairment, functional impairment, and behavior problems. In general, the diagnostic groups differed in symptoms, while most differences in living setting were related to cognition, functioning, and behavior. Nursing home status was significantly associated with more severe overall symptom ratings, worse cognitive impairment, greater functional impairment, more aggressive behaviors, and marital status of having never married. Self-care skills, community living skills, and marital status were most uniquely predictive of nursing home residence. However, cognitive deficits were strongly predictive of both self-care and community living skills, explaining approximately half of the variance in these variables. The implications of these findings for the treatment of elderly patients with schizophrenia and other severe mental illnesses are discussed.

Characteristic hostility in schizophrenic outpatients.

In this study of 133 schizophrenic outpatients, we assessed characteristic hostility and correlates of hostility over a 6-month period. Results showed that 13 percent of the study group were characteristically violent, 18 percent were characteristically threatening, and another 21 percent were irritable and argumentative. About half (48%) were without hostility. A multiple regression model identified six variables--housing instability, hallucinations or delusions, schizoaffective diagnosis, lack of depression, alcohol use, and bizarre behavior--that together accounted for over 50 percent of the variance in observed characteristic hostility. Hostility also predicted rehospitalization and total inpatient days during 1-year followup. Implications of these findings for assessment and future research are discussed.

The aftermath of suicide on the psychiatric inpatient unit.

Suicide in the hospital setting results in a complex array of reactions by the staff, the institution, the remaining patients, the family of the patient, and the outpatient caregivers. In the aftermath of a suicide survivors pass through four predictable and parallel stages: shock, recoil, posttrauma, and recovery. Specific approaches to these stages are addressed. The management of the shock phase requires carefully orchestrated crisis-intervention strategies, containment, and risk management. The numbness and disbelief of this period gives way to the reactions of the recoil phase, which include guilt, shame, anger, depression, self-doubt, and a search for meaning. Group meetings, outreach to the family, the suicide review conference, and, in particular, informal peer contact, are key aspects of recovery in this stage. Family survivors require specialized interventions that take into account the stigmatization that commonly accompanies suicide. In addition, as one fourth to one third of hospital suicides result in lawsuits, specialized approaches to assessment and documentation are indicated. In the posttraumatic phase more general issues of professional efficacy are addressed. The resolution of this phase is enhanced by an open dialogue focusing on the limitations of assessment and treatment of the suicidal patient. Final recovery for staff includes a posture of anticipation appropriate to the clinical setting.

Community-based long-term care for older persons with severe and persistent mental illness in an era of managed care.

The authors describe current needs and trends in the mental health care, including long-term care, of older persons with severe and persistent mental illness. The literature suggests that emerging models of managed long-term care hold promise for integrated services but do not currently address the specialized mental health needs of this patient group. The authors review issues in financing long-term mental health care, including controversies over fee-for-service and carve-out and carve-in arrangements. Without mechanisms to adequately finance services, adjust for risk, and measure outcomes, the authors conclude, managed care arrangements will be in conflict with the goal of high-quality care for older adults with severe and persistent mental illness. Proposed directions for future models of care for this group include integration of mental health and medical services, integration of specialized geropsychiatric services with developing community-based long-term care systems, blended financing under shared risk arrangements, and assurance of accountability and outcomes under managed care.

Long-term course of substance use disorders among patients with severe mental illness.

OBJECTIVE: This study assessed the long-term course of substance abuse and dependence among severely mentally ill patients. METHODS: A prospective, naturalistic, seven-year follow-up of severely mentally ill outpatients (most with schizophrenia and schizoaffective disorder) successfully located and reassessed 79.1 percent (N = 148) of the patients from the original study group. The follow-up study group was assessed for alcohol and drug use at baseline and seven-year follow-up by their case manager or primary clinician using the Case Manager Rating Scale (CMRS) for the assessment of substance-related problems among severely mentally ill patients. RESULTS: The prevalence of active substance use disorder changed little from baseline to follow-up. Alcohol abuse or dependence was present in 24 percent of the patients at baseline and 21 percent at follow-up, and drug abuse or dependence was present in 20 percent at baseline and 17 percent at follow-up. However, those with initial alcohol abuse had a higher rate of remission (67 percent) than those with initial alcohol dependence (33 percent). Similarly, those with initial drug abuse had a higher rate of remission (54 percent) than those with initial drug dependence (31 percent). CONCLUSIONS: The higher rates of change for those with initial substance abuse compared with substance dependence suggest that distinguishing between abuse and dependence may have important implications for assessment and prognosis of individuals with a dual diagnosis of a substance use disorder and severe mental illness.

Sarcopenia, sarcopenic obesity and mortality in older adults: results from the National Health and Nutrition Examination Survey III.

BACKGROUND: Sarcopenia is defined as the loss of skeletal muscle mass and quality, which accelerates with aging and is associated with functional decline. Rising obesity prevalence has led to a high-risk group with both disorders. We assessed mortality risk associated with sarcopenia and sarcopenic obesity in elders. METHODS: A subsample of 4652 subjects ≥60 years of age was identified from the National Health and Nutrition Examination Survey III (1988-1994), a cross-sectional survey of non-institutionalized adults. National Death Index data were linked to this data set. Sarcopenia was defined using a bioelectrical impedance formula validated using magnetic resonance imaging-measured skeletal mass by Janssen et al. Cutoffs for total skeletal muscle mass adjusted for height(2) were sex-specific (men: ≤5.75 kg/m(2); females ≤10.75 kg/m(2)). Obesity was based on % body fat (males: ≥27%, females: ≥38%). Modeling assessed mortality adjusting for age, sex, ethnicity (model 1), comorbidities (hypertension, diabetes, congestive heart failure, osteoporosis, cancer, coronary artery disease and arthritis), smoking, physical activity, self-reported health (model 2) and mobility limitations (model 3). RESULTS: Mean age was 70.6±0.2 years and 57.2% were female. Median follow-up was 14.3 years (interquartile range: 12.5-16.1). Overall prevalence of sarcopenia was 35.4% in women and 75.5% in men, which increased with age. Prevalence of obesity was 60.8% in women and 54.4% in men. Sarcopenic obesity prevalence was 18.1% in women and 42.9% in men. There were 2782 (61.7%) deaths, of which 39.0% were cardiovascular. Women with sarcopenia and sarcopenic obesity had a higher mortality risk than those without sarcopenia or obesity after adjustment (model 2, hazard ratio (HR): 1.35 (1.05-1.74) and 1.29 (1.03-1.60)). After adjusting for mobility limitations (model 3), sarcopenia alone (HR: 1.32 ((1.04-1.69) but not sarcopenia with obesity (HR: 1.25 (0.99-1.58)) was associated with mortality. For men, the risk of death with sarcopenia and sarcopenic obesity was nonsignificant in both model-2 (HR: 0.98 (0.77-1.25), and HR: 0.99 (0.79-1.23)) and model 3 (HR: 0.98 (0.77-1.24) and HR: 0.98 (0.79-1.22)). CONCLUSIONS: Older women with sarcopenia have an increased all-cause mortality risk independent of obesity.

Depressive symptoms in schizophrenia: comprehensive differential diagnosis.

Depression is a common complication of schizophrenia and is associated with increased morbidity and mortality. Contrary to traditional clinical wisdom, depressive symptoms occur during all phases of schizophrenia and are not restricted to the postpsychotic period. In this review, the authors summarize current empirical research and offer a practical approach to the identification of depressive subtypes in schizophrenia. The following subtypes are considered: (1) depressive symptoms occurring secondary to organic factors (caused by medications, substance abuse, or underlying medical problems); (2) nonorganic depressive symptoms occurring with acute psychotic symptoms (intrinsic to the acute psychotic episode or schizoaffective disorder); and (3) nonorganic depressive symptoms occurring without acute psychotic symptoms (prodromal symptoms, negative symptoms, acute dysphoria, secondary depressive syndrome, or chronic demoralization). The authors discuss each of these entities and offer guidelines for diagnosis.

Depression in schizophrenia: current guidelines to treatment.

Depressive symptoms and syndromes in schizophrenia are common but heterogeneous with respect to etiology, presentation, course, and treatment. Based on a comprehensive differential diagnosis that identifies ten clinical subgroups, the authors review relevant treatment studies and offer current treatment guidelines. The clinical recommendations focus on addressing underlying problems such as medication side effects and substance abuse, attempting to identify and treat medication-responsive syndromes, and preventing suicide. The categories and treatments presented here are expected to evolve as researchers continue to elucidate clinically meaningful syndromes and to develop specific treatments. Nevertheless, current knowledge suggests that many schizophrenics with depression and depression-like symptoms can be treated effectively.

Mental health services for Alzheimer's disease. Current trends in reimbursement and public policy, and the future under managed care.

Behavioral or psychiatric symptoms in Alzheimer's disease are strongly related to the use of health care services and result in a significant emotional and financial burden for families. This paper is an overview of major trends in the organization and funding of mental health services for people with Alzheimer's disease, emphasizing specific public policy and reimbursement initiatives that have affected acute and long-term care. Recent trends reflecting increased federal scrutiny of Medicare-reimbursed services and the current and future challenges in providing mental health services to people with Alzheimer's disease within managed care and capitated health plans are also addressed.