Emotional health outcomes are influenced by sexual minority identity and HIV serostatus.

For people living with HIV (PLWH) and sexual minorities (SM), the intersection of identities can compound experiences like stigma and discrimination resulting in poor emotional health. We investigated the separate and interactive associations of HIV serostatus and sexual identity with emotional health. Our dataset included 371 participants. Emotional health was assessed by the NIH Toolbox emotion battery which yields negative affect, social satisfaction, and psychological well-being. Regressions were conducted for each composite, with HIV serostatus, sexual identity, and their interaction as independent variables along with covariates. The HIV serostatus x SM identity interaction was statistically significant in the regression of Negative Affect (p = .01): heterosexuals living with HIV had worse Negative Affect compared to heterosexual HIV-persons (p = .01). The interaction terms were for social satisfaction and psychological well-being were not significant. However, among PLWH, sexual minorities reported better Social Satisfaction (p = .03) and marginally better psychological well-being (p = .07) compared to heterosexuals.

Concerns about aging and caregiving among middle-aged and older lesbian and gay adults.

OBJECTIVES: Despite the increasing number of lesbian and gay older adults, research geared towards health and well-being of this population is limited. Many lesbian and gay seniors experience health disparities and are at risk for poor health outcomes. The aims of this study were to gather in-depth information on the concerns of lesbian and gay elders with respect to aging and care needs. METHOD: The sample included 124 gay men and lesbian women aged 50+ years. Data were gathered via focus groups and questionnaires. The focus groups addressed: (1) concerns about aging in the LGBT community, (2) barriers to needed support and services, (3) concerns about caregiving and (4) needed programs for lesbian and gay seniors. RESULTS: Concerns expressed about aging included: lack of financial security, lack of family or social support, fears about the lack of someone to provide needed care, and discrimination in healthcare or service communities. Participants also indicated concerns about being alone and vulnerable and a need for resources and support programs, specifically for lesbian and gay older adults and for lesbian and gay caregivers. CONCLUSIONS: These findings suggest needed areas of support and programs for older gay men and lesbian women. They also suggest that healthcare professionals might need more training regarding the particular needs and concerns of this community.

Frailty and Neurocognitive Impairment: Impacts on Quality of Life in HIV.

Little is known about the effects of aging-related conditions on health-related quality of life (HRQOL) among people living with HIV (PLWH). The purpose of our study was to examine the independent effects of neurocognitive impairment (NCI) and frailty and the interactive effects with HIV serostatus on HRQOL. Our sample consisted of 121 adults (63 PLWH and 58 HIV-uninfected) participating in the Multi-Dimensional Successful Aging among HIV-Infected Adults study at the University of California, San Diego. HRQOL was measured with the Medical Outcome Study 36-Item Short Form Health Survey scale. We found that frailty was significantly associated with HRQOL (p < .001) in the overall sample, and this effect was significantly stronger for PLWH than HIV-uninfected adults. NCI was not significantly associated with HRQOL in our sample. Frailty may be a particularly important factor in HRQOL for PLWH, highlighting the need for prevention and intervention strategies to mitigate the risks for frailty.

A Novel Method for Direct Assessment of Everyday Competence Among Older Adults.

BACKGROUND: Recent findings indicate that impairments in functional performance do occur among individuals diagnosed with mild cognitive impairment (MCI). Most assessment strategies for everyday competence are associated with challenges with reliability, are typically in paper and pencil format, or require in-person administration by a trained professional. OBJECTIVE: This paper reports on a novel technology-based assessment battery of everyday competence that includes ecologically valid simulations of daily activities important to independence. METHODS: The sample included 85 non-cognitively impaired older adults aged 65+ and 62 older adults diagnosed with amnestic MCI (aMCI). Participants completed standard measures of cognitive abilities and the computerized battery of everyday tasks, which included simulations of a doctor's visit; and medication and financial management tasks. RESULTS: The older adults with aMCI performed significantly poorer on all three tasks in the everyday task battery. Performance on these measures were also moderately correlated with standard measures of cognitive abilities and showed good test-retest reliability. CONCLUSIONS: The results show that it is feasible to use a technology-based assessment battery of everyday tasks with both non-cognitively impaired older adults and older adults with MCI. The use of this type of battery can overcome many of the logistic constraints associated with current functional assessment protocols.

Absence of bias in clinician ratings of everyday functioning among African American, Hispanic and Caucasian patients with schizophrenia.

A substantial research literature implicates potential racial/ethnic bias in the diagnosis of schizophrenia and in clinical ratings of psychosis. There is no similar information regarding bias effects on ratings of everyday functioning. Our aims were to determine if Caucasian raters vary in their ratings of the everyday functioning of schizophrenia patients of different ethnicities, to find out which factors determine accurate self-report of everyday functioning in different ethnic groups, and to know if depression has similar effects on the way people of different ethnicities self-report their current functionality. We analyzed data on 295 patients with schizophrenia who provided their self-report of their everyday functioning and also had a Caucasian clinician rating their functionality. Three racial/ethnic groups (African American (AA), Hispanic and Caucasian) were studied and analyzed on the basis of neurocognition, functional capacity, depression and real-world functional outcomes. No differences based on racial/ethnic status in clinician assessments of patients' functionality were found. Differences between racial groups were found in personal and maternal levels of education. Severity of depression was significantly correlated with accuracy of self-assessment of functioning in Caucasians, but not in AAs. Higher scores on neurocognition and functional capacity scales correlated with reduced overestimation of functioning in AAs, but not in Hispanics. This data might indicate that measurement of everyday functionality is less subject to rater bias than measurement of symptoms of schizophrenia.

Factors influencing self-assessment of cognition and functioning in schizophrenia: implications for treatment studies.

Awareness of illness is a major factor in schizophrenia and extends into unawareness of cognitive and functional deficits. This unawareness of functional limitations has been shown to be influenced by several different predictive factors, including greater impairment and less severe depression. As treatment efforts are aimed at reducing cognitive deficits, discovery of the most efficient assessment strategies for detection of cognitive and functional changes is critical. In this study, we collected systematic assessments from high contact clinicians focusing on their impressions of the cognitive deficits and everyday functioning in a sample of 169 community dwelling patients with schizophrenia. The patients provided self-report on those same rating scales, as well as self-reporting their depression and performing an assessment of cognitive performance and functional skills. There was essentially no correlation between patients' self-reports of their cognitive performance and functional skills and either clinician ratings of these skills or the results of the performance-based assessments. In contrast, clinician reports of cognitive impairments and everyday functioning were correlated with objective performance data. Depression on the part of patients was associated with ratings of functioning that were both more impaired and more congruent with clinician impressions, while overall patients reported less impairment than clinicians. These results underscore the limitations of self-reported cognitive functioning even with structured rating scales. Concurrently, clinicians provided ratings of cognitive performance that were related to scores on objective tests, even though they were unaware of the results of those assessments.

Determinants of different aspects of everyday outcome in schizophrenia: The roles of negative symptoms, cognition, and functional capacity.

Cognition, negative symptoms, and depression are potential predictors of disability in schizophrenia. We present analyses of pooled data from four separate studies (all n>169; total n=821) that assessed differential aspects of disability and their potential determinants. We hypothesized that negative symptoms would predict social outcomes, but not vocational functioning or everyday activities and that cognition and functional capacity would predict vocational functioning and everyday activities but not social outcomes. The samples were rated by clinician informants for their everyday functioning in domains of social and vocational outcomes, and everyday activities, examined with assessments of cognition and functional capacity, rated clinically with the Positive and Negative Syndrome Scale (PANSS) and self-reporting depression. We computed a model that tested the hypotheses described above and compared it to a model that predicted that negative symptoms, depression, cognition, and functional capacity had equivalent influences on all aspects of everyday functioning. The former, specific relationship model fit the data adequately and we subsequently confirmed a similar fit within all four samples. Analyses of the relative goodness of fit suggested that this specific model fit the data better than the more general, equivalent influence predictor model. We suggest that treatments aimed at cognition may not affect social functioning as much as other aspects of disability, a finding consistent with earlier research on the treatment of cognitive deficits in schizophrenia, while negative symptoms predicted social functioning. These relationships are central features of schizophrenia and treatment efforts should be aimed accordingly.

Self-assessment in schizophrenia: Accuracy of evaluation of cognition and everyday functioning.

OBJECTIVE: Self-assessment deficits, often referred to as impaired insight or unawareness of illness, are well established in people with schizophrenia. There are multiple levels of awareness, including awareness of symptoms, functional deficits, cognitive impairments, and the ability to monitor cognitive and functional performance in an ongoing manner. The present study aimed to evaluate the comparative predictive value of each aspect of awareness on the levels of everyday functioning in people with schizophrenia. METHOD: We examined multiple aspects of self-assessment of functioning in 214 people with schizophrenia. We also collected information on everyday functioning rated by high contact clinicians and examined the importance of self-assessment for the prediction of real-world functional outcomes. The relative impact of performance-based measures of cognition, functional capacity, and metacognitive performance on everyday functioning was also examined. RESULTS: Misestimation of ability emerged as the strongest predictor of real-world functioning and exceeded the influences of cognitive performance, functional capacity performance, and performance-based assessment of metacognitive monitoring. The relative contribution of the factors other than self-assessment varied according to which domain of everyday functioning was being examined, but, in all cases, accounted for less predictive variance. CONCLUSION: These results underscore the functional impact of misestimating one's current functioning and relative level of ability. These findings are consistent with the use of insight-focused treatments and compensatory strategies designed to increase self-awareness in multiple functional domains.

The course of vocational functioning in patients with schizophrenia: Re-examining social drift.

Vocational functioning is markedly impaired in people with schizophrenia. In addition to low rates of employment, people with schizophrenia have been reported to be underachieved compared to other family members. Among the causes of this vocational impairment may be cognitive deficits and other skills deficits, as well as social factors impacting on opportunities for employment. In this study, we examined two separate samples of people with schizophrenia who differed in their educational and social backgrounds. We compared personal and maternal education in people with schizophrenia attending an outpatient rehabilitation facility (n = 57) or receiving outpatient services at a VA medical center (n = 39). The sample as a whole showed evidence of decline in vocational status from their best job to their most recent job. Patients attending a rehabilitation facility had completed less education than their mothers, while the VA patients completed more. Differences between personal and maternal education predicted the difference in status between best and latest jobs in the sample as a whole. VA patients were more likely to be living independently and performed better on a measure of functional capacity than the rehabilitation sample. These data implicate vocational decline in schizophrenia and also suggest that this decline may originate prior to the formal onset of the illness. At the same time, vocational outcomes appear to be related to social opportunities.

Self-assessment of functional ability in schizophrenia: milestone achievement and its relationship to accuracy of self-evaluation.

Between 50% and 80% of patients with schizophrenia do not believe they have any illness, and their self-assessment of cognitive impairments and functional abilities is also impaired compared to other information, including informant reports and scores on performance-based ability measures. The present article explores self-assessment accuracy in reference to real world functioning as measured by milestone achievement such as employment and independent living. Our sample included 195 people with schizophrenia examined with a performance-based assessment of neurocognitive abilities and functional capacity. We compared patient self-assessments across achievement of milestones, using patient performance on cognitive and functional capacity measures as a reference point. Performance on measures of functional capacity and cognition was better in people who had achieved employment and residential milestones. Patients with current employment and independence in residence rated themselves as more capable than those who were currently unemployed or not independent. However, individuals who had never had a job rated themselves at least as capable as those who had been previously employed. These data suggest that lifetime failure to achieve functional milestones is associated with overestimation of abilities. As many patients with schizophrenia never achieve milestones, their self-assessment may be overly optimistic as a result.

Functional milestones and clinician ratings of everyday functioning in people with schizophrenia: overlap between milestones and specificity of ratings.

Everyday functioning is known to be impaired in people with schizophrenia, across multiple functional domains. It is not clear, however, how impairments across social, vocational, and residential domains overlap with each other, Further, although there are multiple ratings scales available to rate everyday functioning, it is also not clear how scores on these scales, particularly total scores, relate to milestone achievement. This is important, because efforts to reduce disability with pharmacological or rehabilitative interventions are ultimately evaluated in terms of their impact on everyday functioning, which is often indexed with total scores on rating scales. In this paper from the VALERO study, we report on 195 people with schizophrenia who were rated with a comprehensive process on 6 different functional status rating scales. Milestone achievements in social (ever married or equivalent), vocational (ever employed, currently employed), and residential (living independently, financially responsible) domains were examined for their overlap with each other and with ratings on the rating scales. Total scores on the 6 rating scales were minimally related to milestone achievements and milestone achievements were quite independent of each other. Subscales from two of the rating scales, specifically examining vocational and residential functioning, were specifically related to milestone achievements in their functional domains, but not other milestones. These data suggest that global scores on everyday functioning measures may not capture functional milestones and highlight the fact that functional milestones have multiple determinants other then the ability variables that these rating scales attempt to capture.

Predictors of the accuracy of self assessment of everyday functioning in people with schizophrenia.

Despite multiple lines of evidence suggesting that people with schizophrenia have substantial problems in self-reporting everyday functioning and cognitive performance, self-report methods are still widely used to assess functioning. This study attempted to identify predictors of accuracy in self report, both in terms of accurate self-assessment and over-estimation of current functioning. As part of the larger Validating Assessments of Everyday Real-World Outcomes (VALERO) study, 195 patients with schizophrenia were asked to self report their everyday functioning with the Specific Levels of Functioning (SLOF) scale, which includes subscales assessing social functioning, everyday activities, and vocational functioning. They were also assessed with measures of neuropsychological (NP) performance and functional capacity (FC), and were assessed for psychiatric symptomatology. In addition, a friend, relative or clinician informant was interviewed with the SLOF, and an interviewer with access to all information provided by the patient and informant (exclusive of performance-based data) generated "best estimate" ratings of actual, everyday functioning. Patients significantly (p<.001) overestimated their vocational functioning and everyday activities compared to the interviewer judgments. Lower levels of NP and FC performance and everyday functioning on the part of patients were consistently associated with overestimation of their functioning. Patient self-reports were not correlated with any performance-based measures, while interviewer judgments were significantly correlated with patients' performance on NP and FC measures (p<.005). In regression analyses, adjusting for interviewer ratings of functioning, several predictors of the discrepancy between self and interviewer judgments emerged. Higher levels of depressive symptoms were associated with less overestimation in self-reports (p<.001). Delusions, suspiciousness, grandiosity and poor rapport were all significantly (p<.001) associated with over-estimation of functioning compared to interviewer judgments. Poorer NP and FC performance were also associated with over-estimation of everyday functioning, but these results were not statistically significant in multivariate regression models. Consistent with previous studies in schizophrenia, other neuropsychiatric conditions and non-clinical populations, higher levels of depression were associated with increased accuracy in self-assessment. Similarly, lower scores on performance-based measures and judgments of everyday functioning also predicted over-estimation of functioning. Thus, we identified bi-directional predictors of mis-estimation of everyday functioning, even when poor baseline scores were considered. These data suggest that it may be possible to screen patients for their ability to self-report their functioning, but that performance-based measures of functioning provide a less biased assessment.

Assessing everyday functioning in schizophrenia: not all informants seem equally informative.

Self reports of everyday functioning on the part of people with schizophrenia have been found to be poorly correlated with the reports of other informants and with their own performance of tests of cognition and functional abilities. However, it is not clear which informants are best for providing accurate reports of everyday functioning. This study examined the convergence between self-reports on the part of people with schizophrenia (n=193), whose real-world functioning was rated by a friend or relative (n=154), or a high contact clinician (n=39) across 6 functional status rating scales. In addition, correlations between these reports and patient's performance on neuropsychological tests and a performance-based measure of functional capacity were also calculated. For convergence between raters, friend or relative informants and patient reports were significantly correlated for 4/6 rating scales. For the smaller sample of clinician informants, the correlations were significant on 2/6 scales. In the analyses of convergence between patient performance scores and functioning ratings, only 1/12 correlations between patient report and performance were significant, while friend or relative reports also were only correlated with performance on one rating scale. In contrast, clinician reports of functioning were correlated with patients' functional capacity performance on 4/6 rating scales and with neuropsychological test performance on 2/6. High contact clinicians appear to generate ratings of everyday functioning that are more closely linked to patients' ability scores than friend or relative informants. Later analyses will determine if there are differences between friend or relative informants.