Suicidal behavior in Mexican adolescents: A test of a latent class model using two independent probability samples.

Suicidal behavior is a serious health issue that affects the adolescent population and that may be prevented through evidence-based approaches. There are many risk factors involved in suicidal behavior, but there are few studies encompassing the complex relationships between them. This study tested the similarity between two latent class models from two different epidemiological samples of middle-school students and evaluated if the multinomial regression model replicated the associations between the classes and the psychosocial variables. Data of 4013 adolescents from the Mexican states of Campeche and Querétaro were included in LCA to characterize suicide behavior and associated factors. The most likely latent class membership was used as the outcome in multinomial regression models. The model with data from Querétaro was consistent with the previous LC model from Campeche. The four latent classes were nearly identical for both populations and can be defined as follows: 1) "No Problems," included 73% of the adolescents; 2) "Drug Use Only," comprised 7% of the adolescents; 3) "Suicidal Behavior, No Depression," captured 8% of the adolescents (25% reported binge drinking in the past month, 50% self-inflicted injuries, and 43% low-lethality suicide attempt); 4) "Depression and Suicidal Behavior," comprised 12% of the sample (66% met criteria for Major Depressive Episode, 28% reported binge drinking in the past month, and 11% had a high-lethality suicide attempt). The congruence between the models and the consistency with identified factors highlight the need for appropriate and effective prevention strategies to minimize risk factors and reinforce protective factors in the adolescent population.

Understanding suicidal behavior and its prevention among youth and young adults in Mexico.

Suicide rates in Mexico have increased and have more than doubled in the state of Aguascalientes over the past 10 years. Few studies have been able to control for family, neighborhood, and occupational environment factors that may confound the association between psychosocial characteristics and suicidal behavior. We study suicidal behavior among adolescents and young adults in Mexico utilizing epidemiologic research strategies to overcome prior research deficiencies. In a case-control study with youth and adults 14-42 years of age, recent cases of severe suicidal behavior (n = 150) were individually matched with up to three controls who had never had a suicidal attempt by age and sex, as well as within familial, neighborhood, and occupational contexts (n = 353). Data were collected through standardized face-to-face interviews to measure suicidal behavior and several covariates, including family relations, psychological resources, hopelessness, depression, self-esteem, stress, impulsivity, anxiety, and substance use. All measures demonstrated good to excellent precision and accuracy. Compared with their matched controls, cases perceived life events as more stressful and had worse depression and familial relationships; poorer development of affective, religious, and social resources; higher levels of hopelessness and impulsive behavior; and lower self-esteem. Evidence from multivariate analysis suggests highly probable MDE combined with low self-esteem and the use of two or more drugs in the past month more clearly differentiate cases and controls and, therefore, may best predict suicidal attempt among adolescents and young adults in Aguascalientes, Mexico.

Addressing Tobacco Use in Underserved Communities Through a Peer-Facilitated Smoking Cessation Program.

Communities Engaged and Advocating for a Smoke-Free Environment (CEASE) is a long-standing research partnership between a university and the neighboring community that was established to reduce tobacco use among poor and underserved residents. The CEASE tobacco cessation program was implemented in four phases, with each new phase applying lessons learned from the previous phases to improve outcomes. This study describes CEASE's community-based approach and reports results from implementing the second phase of the intervention which, among other things, varied in the type of incentives, setting, and providers used. CEASE implemented a mixed-methods study following the Community-Based Participatory Research (CBPR) approach. During Phase II, a total of 398 smokers were recruited into two 12-session group counseling interventions facilitated by trained peers in community venues, which differed in the type of incentives used to increase participation and reward the achievement of milestones. At 12-week follow-up, 21% of all participants reported not smoking, with a retention rate (i.e., attendance at six or more of the 12 cessation classes offered) of 51.9%. No significant differences in cessation outcomes were found between the two study arms. Using a CBPR approach resulted in a peer-led model of care with improved outcomes compared to Phase I, which was provided by clinicians. The combined use of monetary and non-monetary incentives was helpful in increasing participation in the program but did not significantly impact smoking cessation. A CBPR approach can increase the acceptability and effectiveness of cessation services for underserved populations.

Suicide behavior and associated psychosocial factors among adolescents in Campeche, Mexico.

Suicide is an important public health problem that requires a preventive approach. The present study aimed at assessing suicidal behaviors and their relations with other psychosocial factors in Campeche, Mexico, in order to inform the design of potential preventive interventions. A multistage probability sample of 2386 students representative of all middle schools of the state of Campeche, Mexico, took a standardized, paper-and-pencil survey covering selected psychosocial constructs including suicide behavior, depression, drug use, familial relationships, locus of control, impulsivity, and self-esteem, among others. Latent classes were identified and multinomial logistic regression was used to analyze associations between class membership and psychosocial covariates. An estimated 8% of the middle school population in Campeche had three or more psychosocial problems in the past month including drug use, major depression episode symptoms, as well as suicidal problems like attempts and self-inflicted injuries. Four latent classes were identified, one with lowest risk and three with varying characteristics in terms of binge alcohol and other drug use, depression, and suicide behaviors. Associations between psychosocial covariates and latent class were observed, as predicted based on a multi-dimensional theoretical framework. Heterogeneity across "High-Risk" groups and their potential determinants highlight the need for differentiated, specialized efforts ranging from universal to indicated interventions. Given the high level of risk factors in this population, universal preventive interventions should aim at building resiliency among youth by helping them develop an array of coping resources, as well as by creating a more nurturing psychosocial environment.

Examining Smoking Cessation in a Community-Based Versus Clinic-Based Intervention Using Community-Based Participatory Research.

Tobacco use remains a major public health problem in the U.S. disproportionately affecting underserved communities. The Communities Engaged and Advocating for a Smoke-free Environment (CEASE) initiative is an intervention to address the problem using a community-based participatory research (CBPR) approach. This study compares quit rates in a peer-led community-based intervention with those achieved in a clinical setting. The intervention consisted of three Phases. Phase I (n = 404) was a clinic-based trial comparing two types of counseling. Phase II (n = 398) and Phase III (n = 163) interventions were conducted in community venues by trained Peer Motivators. Quit rates at 12-week follow-up increased from 9.4 % in Phase I (clinic-based) to an average of 23.7 % in Phases II and III combined (community-based). The main predictor of smoking cessation was delivery of services in community settings (OR 2.6, 95 % CI 1.7-4.2) while controlling for possible confounders. A community-based approach can significantly guide and improve effectiveness and acceptability of smoking cessation services designed for low-income urban populations. In addition, CBPR can result in better recruitment and retention of the participants.

Nonmedical use of prescription drugs in emerging adulthood: differentiating sex from gender.

Male-female variations in health-behavior continue to be of national and international significance with men generally being more likely to be engaged in behaviors that enhance risk across an array of preventable diseases and injuries as well as premature deaths. The literature has identified non-medical use of prescription drugs (NMUPD) as a developing and particularly dangerous substance use behavior among college students. The literature has reported sex differences (male; female) in NMUPD but has yet to explain how gender-orientation (e.g., masculine, feminine) might impact NMUPD. The purpose of this study is to address this gap by examining the influence of gender-orientation on NMUPD. Using survey data collected during the 2013-2014 academic year from a convenience sample of college students at a mid-sized Midwestern university, we examine the association of gender-orientation with NMUPD (N=796). To do this, we separate masculine and feminine scales from the BEM Sex Role Inventory and use logistic regression to test whether masculine or feminine gender characteristics influence the likelihood of NMUPD (lifetime measure of any use and by category). This analysis shows that self-identified characteristics associated with masculinity increase the odds of NMUPD while femininity is associated with lower odds of NMUPD. Findings from this study increase our knowledge of gender-orientation and sex interactions as factors that might influence NMUPD thus demonstrating the importance of differentiating sex from gender-orientation.

Depressive symptoms among adolescents and older adults in Mexico City.

PURPOSE: Determine the structure of depressive symptoms among adolescents and older adults through the person-centered approach of latent class analysis (LCA). METHODS: The study is based on data from two independent samples collected in Mexico City (2,444 adolescents and 2,223 older adults) which included the revised version of the CES-D. The presence or absence of depressed mood (dysphoria), diminished pleasure (anhedonia), drastic change in weight, sleep problems, thinking and concentration difficulties, excessive or inappropriate guilt, fatigue, psychomotor agitation/retardation, and suicide ideation were used in LCA to determine the structure of depressive symptoms for adolescents and older adults. RESULTS: Adolescents reported higher excessive or inappropriate guilt compared to older adults, while older adults had higher proportions of anhedonia, sleep problems, fatigue, and psychomotor agitation/retardation. Similar proportions were found in other symptoms. The LCA analysis showed the best fit with four latent classes (LC): LC 1, "symptoms suggestive of major depressive episode (MDE)" with prevalence of 5.9 % (n = 144) and 10.3 % (n = 230) among adolescents and older adults, respectively; LC 2, "probable MDE symptoms" 18.2 % (n = 446) and 23.0 % (n = 512); LC 3, "possible MDE" 27.7 % (n = 676) and 21.8 % (n = 485); LC 4, "without significant depressive symptoms" 48.2 % (n = 1,178) and 44.8 % (n = 996). The differences in item thresholds between the two groups (adolescents vs. older adults) were statistically significant (Wald test = 255.684, df = 1, p < 0.001). CONCLUSIONS: This study documented important similarities and differences in the structure of depressive symptoms between adolescents and older adults that merit acknowledgment, further study, and consideration of their potential clinical and public health implications.

Factors associated with help-seeking behaviors in Mexican older individuals with depressive symptoms: a cross-sectional study.

OBJECTIVE: Depression in the older individuals is associated with multiple adverse outcomes, such as high health service utilization rates, low pharmacological compliance, and synergistic interactions with other comorbidities. Moreover, the help-seeking process, which usually starts with the feeling "that something is wrong" and ends with appropriate medical care, is influenced by several factors. The aim of this study was to explore factors associated with the pathway of help seeking among older adults with depressive symptoms. METHODS: A cross-sectional study of 60-year or older community dwelling individuals belonging to the largest health and social security system in Mexico was carried out. A standardized interview explored the process of seeking health care in four dimensions: depressive symptoms, help seeking, help acquisition, and specialized mental health. RESULTS: A total of 2322 individuals were studied; from these, 67.14% (n = 1559) were women, and the mean age was 73.18 years (SD = 7.02); 57.9% had symptoms of depression; 337 (25.1%) participants sought help, and 271 (80.4%) received help; and 103 (38%) received specialized mental health care. In the stepwise model for not seeking help (χ(2) = 81.66, p < 0.0001), significant variables were female gender (odds ratio (OR) = 0.7, 95% confidence interval (CI) 0.511-0.958, p = 0.026), health-care use (OR 3.26, CI 95% 1.64-6.488, p = 0.001). Number of years in school, difficulty in activities, Short Anxiety Screening Test score, and indication that depression is not a disease belief were also significant. CONCLUSIONS: Appropriate mental health care is rather complex and is influenced by several factors. The main factors associated with help seeking were gender, education level, recent health service use, and the belief that depression is not a disease. Detection of subjects with these characteristics could improve care of the older individuals with depressive symptoms.

Utilizing User Preferences in Designing the AGILE (Accelerating Access to Gender-Based Violence Information and Services Leveraging on Technology Enhanced) Chatbot.

INTRODUCTION: Technology advancements have enhanced artificial intelligence, leading to a user shift towards virtual assistants, but a human-centered approach is needed to assess for acceptability and effectiveness. The AGILE chatbot is designed in Kenya with features to redefine the response towards gender-based violence (GBV) among vulnerable populations, including adolescents, young women and men, and sexual and gender minorities, to offer accurate and reliable information among users. METHODS: We conducted an exploratory qualitative study through focus group discussions (FGDs) targeting 150 participants sampled from vulnerable categories; adolescent girls and boys, young women, young men, and sexual and gender minorities. The FGDs included multiple inquiries to assess knowledge and prior interaction with intelligent conversational assistants to inform the user-centric development of a decision-supportive chatbot and a pilot of the chatbot prototype. Each focus group comprised 9-10 members, and the discussions lasted about two hours to gain qualitative user insights and experiences. We used thematic analysis and drew on grounded theory to analyze the data. RESULTS: The analysis resulted in 14 salient themes composed of sexual violence, physical violence, emotional violence, intimate partner violence, female genital mutilation, sexual reproductive health, mental health, help-seeking behaviors/where to seek support, who to talk to, and what information they would like, features of the chatbot, access of chatbot, abuse and HIV, family and community conflicts, and information for self-care. CONCLUSION: Adopting a human-centered approach in designing an effective chatbot with as many human features as possible is crucial in increasing utilization, addressing the gaps presented by marginalized/vulnerable populations, and reducing the current GBV epidemic by moving prevention and response services closer to people in need.

Higher perceived stress during admission is associated with shorter retention in short-term residential substance use disorder treatment.

Introduction: Over one million people in the U.S. received residential treatment for a substance use disorder (SUD) in 2020. Longer treatment retention is associated with better outcomes (e.g., reduced substance use). Entering treatment with higher stress may be associated with shorter retention. This paper examines the impact of perceived stress at admission on SUD treatment retention in short-term residential treatment. Methods: A sample of 271 treatment episodes with admissions between October 2019 and February 2020 were collected from de-identified records of an urban mid-Atlantic adult 28-day short-term residential SUD treatment facility. Treatment completion involved finishing 28 days. Sociodemographic, substance use, perceived stress, and treatment discharge variables were analyzed. Bivariate analyses examined differences between treatment completion and early discharge, and Cox regression investigated the effect of perceived stress on treatment retention with covariates. Results: The sample was primarily male (73.8%) and non-Hispanic Black (71.6%). A majority used heroin as their primary substance (54.6%) and reported polysubstance use (72.3%). About half (51.3%) completed treatment, and completed an average of 18.7 (SD = 10.7) days. Those who prematurely discharged from treatment stayed an average of 8.9 (SD = 7.0) days. The Cox regression model found that higher perceived stress (adjusted hazard ratio (AHR) = 1.028; 95% CI = [1.005, 1.053], p =.019) and a race/ethnicity other than non-Hispanic Black (AHR = 1.546, 95% CI = [1.037, 2.305], p =.033) predicted premature discharge. Conclusions: Perceived stress at admission is associated with shorter treatment retention. Early stress management interventions may help increase treatment retention.

Comparison of suicide attempts among nationally representative samples of Mexican adolescents 12 months before and after the outbreak of the Covid-19 pandemic.

BACKGROUND: There is serious concern over the increase in mental health problems during the coronavirus disease 2019 (Covid-19) pandemic. METHODS: Based on data from two Mexican National Health and Nutrition Surveys conducted in 2018-2019 and 2020 (n = 17,925 and 4,913, respectively), we estimated the prevalence of suicide attempts among adolescents 10-19 years old in the previous year. We constructed a multivariate logistic regression model adjusted by sociodemographic characteristics and contextual variables for the Covid-19 pandemic. RESULTS: The prevalence of suicide attempts in the previous year was similar in both surveys. We found that women, youth in urban localities and individuals living in households where a family member had lost her/his job as a result of the Covid-19 contingency were more likely to attempt suicide compared to their counterparts. On the other hand, attending classes online proved to be a protective factor (aOR=0.3, 95% CI=0.1, 0.8, p = 0.022). LIMITATIONS: The principal limitation of our study concerned the restricted size of our sample for the 2020 survey wave. CONCLUSIONS: Population-level policies aimed at providing economic protection and helping youth to return to school would exert a favorable impact on the mental health and suicidal behavior of youths.

Building Equitable Community-Academic Partnerships for Opioid Recovery Research: Lessons Learned from Stakeholder Engagement With Peer and Provider Organizations.

Forming equity-based community-academic partnerships focused on recovery research is a time- consuming and challenging endeavor, but one well worth the care and effort required. Through building trusting relationships, vital research collaborations emerge, which are driven by expressed community needs and supported with university resources. This article describes the stakeholder engagement process utilized by a university-based and opioid-focused initiative entitled Innovations in Recovery through Infrastructure Support (IRIS). IRIS developed a diverse and representative network of clinical providers, peer recovery workers, academics, and other behavioral health leaders. The process was informed by community-based participatory research (CBPR) practices and principles aimed at creating equitable partnerships. Lessons learned include the need to reshape the relationship between research and the community through an acknowledgment of harms committed by academia, as well as the importance of maintaining an approach of humility, accountability, and patience with the partnership process. Concrete benefits that go beyond the long-term promise of change, including compensating partners financially for their time, help ensure equity. A commitment to always asking "Who's missing?" and then filling those gaps builds a broad network inclusive of the various constituencies that make up the recovery support system. As IRIS builds on these lessons learned and plans next steps, we share our experience to support others engaged in forming community-academic partnerships through deep stakeholder engagement and use of participatory approaches within and outside of recovery research.

Voices from the Youth in Kenya Addressing Mental Health Gaps and Recommendations.

Studies including adolescents and young people (AYP) enhance the relevance of research results, benefit stakeholders, and inform future research. There exists a mental health gap in services for AYP living in low and middle-income countries. This study aims to identify mental health challenges faced by adolescents and young people in Kenya, develop practical recommendations to mitigate these issues, and reduce the mental health burden among this population. We convened an AYP-led meeting that involved 41 participants. The meeting objectives were to (1) identify efforts to support existing national and regional strategic priorities and review goals for addressing mental health needs among AYPs, (2) develop immediate action plans for strengthened mental health services, (3) review and strengthen country-level coordination mechanisms, and (4) identify how participating county experiences can inform mental health services in Kenya. Ministry of Health (MoH) officials from national and county levels, academic experts, and implementing partner agencies involved in mental health services participated in the meeting. The team, including AYP representatives, identified various mental health challenges among the AYA and recommended interventions aimed towards improving their mental health situation in the country. The challenges were clustered into three themes and comprehensively reviewed to establish the precipitating factors to mental health outcomes among AYPs in Kenya and provide recommendations. The themes included (1) legislative, (2) service provider/Ministry of Health, and (3) adolescent/individual-level factors. To bridge the mental health gap in the country and scale up mental health outcomes, the stakeholders recommended interventions within the context of the three clusters. The key suggestions included an increase in insurance financing, acceleration of community health interventions, the establishment of adolescent-friendly spaces, the training of adolescent youth champions, interactive service provision models, implementation of the existing mental health policies and structures, the development of comprehensive assessment tools, well equipped mental health departments in health facilities, the enhancement of telehealth services and digital villages, the mobilization of a functional mental health response team, and the development of a mental health database.

Early sexual experience and later onset of illegal drug use among African American students on HBCU campuses.

Few studies examine whether early sexual experience is associated with subsequent illegal drug use among adolescents. A sample of 7,372 African American students who had not used illegal drugs before the age of 14 were identified in the dataset of the 2001 Historically Black Colleges and Universities (HBCU) Substance Use Survey. Using self-reported ages of onset, discrete-time survival models estimated the hazard of illegal drug use onset after age 13 subsequent to first sexual intercourse. Early sex was modestly associated with subsequent illegal drug initiation, particularly among females. Drug use prevention services should be provided to youth engaged in early sexual activity.

Comparative Analysis of Lifetime Suicide Attempts among Mexican Adolescents, over the Past 12 Years.

OBJECTIVE: To compare the occurrence of suicide attempts across nationally representative samples of the Mexican adolescent population over the past 12 years, and to analyze its association with sociodemographic, lifestyle and mental-health indicators. METHODOLOGY: Data were drawn from the 2006, 2012 and 2018 National Health and Nutrition Surveys (n = 25,056; 21,509; and 17,925 adolescents, respectively). Estimates were based on standardized measurements. RESULTS: The estimated lifetime prevalence rates of suicide attempts were 1.1% in 2006, 2.7% in 2012, and 3.9% in 2018, indicating a 3.4-fold increase. Across the three survey periods, women yielded rates nearly three times higher than men. Lifetime prevalence grew the most among adolescents aged 13-15 years. Compared to the other respondents, the odds of lifetime suicide attempts proved seven times as high for those who had been sexually abused during their childhood, five times as high for those who had been diagnosed with a depressive disorder, three times as high for those who had suffered physical aggression and twice as high for those who had smoked 100+ cigarettes in their lifetimes and those who consumed alcohol. CONCLUSION: The sharp increase in suicide attempts in Mexico calls for an urgent public-health response via universal and targeted interventions supported by national policy and sustained federal funding.

Psychosocial Correlates of Suicidal Behavior among Adolescents under Confinement Due to the COVID-19 Pandemic in Aguascalientes, Mexico: A Cross-Sectional Population Survey.

Background: Suicide and suicidal behaviors were already a global public health problem, producing preventable injuries and deaths. This issue may worsen due to the COVID-19 pandemic and may differentially affect vulnerable groups in the population, including children, adolescents, and young adults. The current study evaluated the association of affective variables (depression, hopelessness, and anxiety), drug use (alcohol, tobacco, and others), emotional intelligence, and attachment with suicidal behaviors. Methods: A state-wide survey included 8033 students (51% female, 49% male; mean age of 16 years) from science and technology high-schools using a standardized questionnaire that was distributed online. Multinomial logistic regression models tested associations between suicidal behaviors and several covariates. The analyses accommodated the complex structure of the sample. Results: Approximately 21% of all students reported a suicidal behavior (11% with a low-lethality suicide attempt, 6% with self-injuries, and 4% with a high-lethality suicide attempt). Variables associated with higher odds of suicidal behavior included: female sex, depression, hopelessness, anxiety, alcohol and tobacco use, childhood trauma, and having to self-rely as issues affecting attachment, and low self-esteem. Security of attachment was associated with lower odds of suicidal behavior. Conclusions: The complexity of suicidal behavior makes it clear that comprehensive programs need to be implemented.

Children as innovators: harnessing the creative expertise of children to address practical and psychosocial challenges of the coronavirus disease 2019 (COVID-19) pandemic - COVISION study protocol.

Background: We are currently in a period of transition, from the pre-COVID-19 (coronavirus disease 2019) era and the initial reactive lockdowns, to now the ongoing living with and potentially the after COVID-19 period. Each country is at its own individual stage of this transition, but many have gone through a period of feeling adrift; disconnected from normal lives, habits and routines, finding oneself betwixt and between stages, similar to that of liminality. Children and young people have been particularly affected. Aim: To increase the understanding of home and community-based strategies that contribute to children and young people's capacity to adjust to societal changes, both during and after pandemics. Moreover, to identify ways in which children's actions contribute to the capacity of others to adjust to the changes arising from the pandemic. The potential for these activities to influence and contribute to broader social mobilisation will be examined and promoted. Research design: To achieve the aim of this study, a participatory health research approach will be taken. The overarching theoretical framework of the COVISION study is that of liminality. The study design includes four work packages: two syntheses of literature (a rapid realist review and scoping review) to gain an overview of the emerging international context of evidence of psychosocial mitigations and community resilience in pandemics, and more specifically COVID-19; qualitative exploration of children and young people's perspective of COVID-19 via creative outlets and reflections; and participatory learning and action through co-production.

Racial/ethnic differences in parental concern about their child's drug use in a nationally representative sample in the United States.

INTRODUCTION: Parental concern and negative attitudes toward drug use may prevent youth from being involved in drug use. However, few studies have addressed parental concern about children's drug use and its possible variation by race/ethnicity. In this study, we explored the potential racial/ethnic differences in parental concern about their children's drug use with a nationally representative sample. METHODS: The data were from the 2003 National Survey of Children's Health, a random household telephone survey of parents of children up to age 17 (n = 102353). The analytic sample was restricted to parents of children aged 6 to 17 years (n = 61046). Multivariate logistic regression models, controlling for children's age, gender, family structure, and family poverty level, were fitted, simultaneously accommodating the complex survey design. RESULTS: Parents of African American and Hispanic children expressed more concern than parents of white children, even after controlling for potential confounders (adjusted odds ratio (AOR), 1.9; 95% CI, 1.8-2.1 and AOR, 1.9; 95% Cl, 1.7-2.1, respectively). CONCLUSIONS: The level of parental concern about adolescent drug use was different across race/ethnicity groups. The results may have implications for parental participation in school-based adolescent prevention programs.

Social networks and health-related quality of life: a population based study among older adults.

OBJECTIVE: To examine the relationship between components of social networks and health-related quality of life (HRQL) in older adults with and without depressive symptoms. MATERIAL AND METHODS: Comparative cross-sectional study with data from the cohort study 'Integral Study of Depression', carried out in Mexico City during 2004. The sample was selected through a multi-stage probability design. HRQL was measured with the SF-36. Geriatric Depression Scale (GDS) and the Short Anxiety Screening Test (SAST) determined depressive symptoms and anxiety. T-test and multiple linear regressions were conducted. RESULTS: Older adults with depressive symptoms had the lowest scores in all HRQL scales. A larger network of close relatives and friends was associated with better HRQL on several scales. Living alone did not significantly affect HRQL level, in either the study or comparison group. CONCLUSIONS: A positive association between some components of social networks and good HRQL exists even in older adults with depressive symptoms.