HIV Prevention Method Preferences Within Sexual Partnerships Reported by HIV-Negative MSM and TW in Tijuana, Mexico.

To assess the potential for decreased condom use as pre-exposure prophylaxis (PrEP) is scaled-up in Latin America, we examined HIV prevention method preferences (neither PrEP nor condoms, condoms only, PrEP only, or PrEP with condoms) within 1302 sexual partnerships reported by 397 HIV-negative men who have sex with men (MSM) and transgender women (TW) in Tijuana, Mexico. Using PrEP with condoms (56%) was preferred to using condoms only (24%), using PrEP only (17%), and using neither PrEP nor condoms (3%). Compared to using condoms only, using PrEP only was preferred within primary (adjusted odds ratio [AOR] = 4.13, 95% confidence interval [CI] 1.92, 8.90) and condomless sex practicing (AOR = 6.97, 95% CI 3.92, 12.40) partnerships, suggesting PrEP use may not displace condom use among MSM and TW in Tijuana and other similar settings.

Current smoking is associated with worse cognitive and adaptive functioning in serious mental illness.

OBJECTIVE: Cigarette smoking is highly prevalent among people with bipolar disorder or schizophrenia. Few studies have examined whether smoking history is associated with adaptive functioning among individuals diagnosed with these serious mental illnesses. METHOD: In a large relatively homogenous cohort of patients with either bipolar disorder (n=363) or schizophrenia (n=400), we investigated the association between cigarette smoking status, intensity, and cumulative exposure and performance on a comprehensive battery of neurocognitive, functional capacity, and informant-rated functional measures. The associations were adjusted for variation in sociodemographic indicators, psychopathologic symptoms, and substance use. RESULTS: There was an average of 12 pack years of smoking across the sample. People with schizophrenia reported double the rate of current smoking compared to patients with bipolar disorder. Adjusting for demographic covariates, current smokers had worse composite cognitive functioning and poorer functional outcome than past or never smokers. There were no significant differences between never and past smokers, and these effects were evident in both bipolar disorder and schizophrenia. CONCLUSION: Current smokers with either schizophrenia or bipolar disorder evidence worse cognitive and adaptive functioning functional outcome, even when demographic covariates are considered.

Analysis of the moderating effect of self-efficacy domains in different points of the dementia caregiving process.

INTRODUCTION: Studies analyzing the moderator role of self-efficacy have centered their attention on the relationship between stressors and distress. However, drawing upon the stress and coping model, the moderator effects of self-efficacy may appear in the relationship between other key elements of the stress process. OBJECTIVES AND METHOD: The purpose of this study was to analyze, in a sample of 167 dementia family caregivers, (1) the moderating effect of self-efficacy for managing behavioral problems on the relationship between frequency of behavioral problems and burden; and (2) the moderating effect of self-efficacy for controlling upsetting thoughts on the relationship between burden and caregivers' distress (depression and anxiety). RESULTS: While no support has been found for the hypothesis that self-efficacy for managing behavioral problems moderates the relationship between frequency of behavioral problems and burden, our findings support the moderator role of self-efficacy for controlling upsetting thoughts in the relationship between burden and distress. No differences in distress measures are found between caregivers with high and low scores on self-efficacy for controlling upsetting thoughts when they report low levels of burden. However, when the levels of burden are high, caregivers with high self-efficacy for controlling upsetting thoughts report significantly lower levels of distress than caregivers with low self-efficacy for controlling upsetting thoughts. CONCLUSION: Self-efficacy for controlling upsetting thoughts may be particularly effective for caregivers who report high burden scores, attenuating the impact of burden on caregivers' distress (depression and anxiety).

Associations between migrant status and sexually transmitted infections among female sex workers in Tijuana, Mexico.

OBJECTIVE: To examine associations between migration and sexually transmitted infection (STI) prevalence among Mexican female sex workers (FSW). METHODS: FSW aged 18 years and older in Tijuana, Baja California (BC) underwent interviews and testing for HIV, syphilis, gonorrhoea and chlamydia. Multivariate logistic regressions identified correlates of STI. RESULTS: Of 471 FSW, 79% were migrants to BC. Among migrant FSW, prevalence of HIV, syphilis, gonorrhoea, chlamydia and any STI was 6.6%, 13.2%, 7.8%, 16.3% and 31.1% compared with 10.9%, 18.2%, 13.0%, 19.0% and 42.4% among FSW born in BC. A greater proportion of migrant FSW were registered with local health services and were ever tested for HIV. Migrant status was protective for any STI in unadjusted models (unadjusted odds ratio 0.61, 95% CI 0.39 to 0.97). In multivariate models controlling for confounders, migrant status was not associated with an elevated odds of STI acquisition and trended towards a protective association. CONCLUSIONS: Unexpectedly, migrant status (vs native-born status) appeared protective for any STI acquisition. It is unclear which social or economic conditions may protect against STI and whether these erode over time in migrants. Additional research is needed to inform our understanding of whether or how geography, variations in health capital, or social network composition and information-sharing attributes can contribute to health protective behaviours in migrant FSW. By capitalising on such mechanisms, efforts to preserve protective health behaviours in migrant FSW will help control STI in the population and may lead to the identification of strategies that are generalisable to other FSW.

Oral and vaginal HIV pre-exposure prophylaxis product attribute preferences among female sex workers in the Mexico-US border region.

To assess the potential uptake of HIV pre-exposure prophylaxis (PrEP) products among female sex workers (FSWs) vulnerable to HIV infection, we examined the influence of product attributes on willingness to use products among 271 HIV-negative FSWs in Tijuana and Ciudad Juarez, Mexico (2016-2017). Via five-point Likert scale ratings, participants indicated their willingness to use hypothetical products with six attributes: formulation (pill, gel, liquid, or ring), frequency of use (daily, on-demand, or monthly), cost per use (10 or 200 pesos), effectiveness (40% or 80%), side effects (none or mild), and access point (healthcare clinic or non-governmental organization). Conjoint analysis was used to determine the impact of attributes on product ratings and identify preferred product attributes. Multinomial logistic regression was used to identify factors associated with formulation preferences. In both cities, formulation and frequency of use had the greatest impact on ratings. Participants in Ciudad Juarez indicated a strong preference for oral pills, whereas participants in Tijuana indicated roughly equal preferences for oral pills and vaginal gels. Monthly product use was preferred in both cities. Compared to preferring oral pills (38%), preferring vaginal gels (28%) was associated with practicing vaginal lubrication (adjusted odds ratio = 2.08; 95% confidence interval: 1.07-4.04). Oral PrEP may be acceptable to many FSWs in Tijuana and Ciudad Juarez; however, continued development of behaviorally-congruent vaginal PrEP products may also facilitate uptake and ensure sufficient coverage.

First molecular surveillance report of HIV type 1 in injecting drug users and female sex workers along the U.S.-Mexico border.

HIV prevalence is increasing among high-risk populations in the Mexican-U.S. border cities of Tijuana and Ciudad Juarez. In 2005, the molecular epidemiology of HIV-1 was studied among injecting drug users (IDU) and female sex workers (FSW) in these cities, which are corridors for over two-thirds of the migrant flow between Mexico and the United States. Eleven samples (eight IDU and three FSW) were successfully amplified, sequenced, and analyzed. The results revealed that all 11 samples were subtype B. There was no phylogenetic clustering or separation of the strains between IDU and FSW or between Tijuana and Ciudad Juarez nor was the Mexican strain phylogenetically distinct from other subtype B strains. Two of three drug naive FSWs had low-level HIV-1 resistance mutations. This community-based study demonstrated that HIV-positive IDUs and FSWs in Ciudad Juarez and Tijuana were predominantly infected with subtype B. Further prevalence studies on HIV-1 resistance mutations among FSWs in these border cities are warranted.

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.

Social supports in relation to physical health and symptoms of depression in the elderly.

The authors examined the relationship of social supports to physical and psychological well-being in 118 men and women 65 years old or older who were living independently in the community. Subjects with more symptoms of depression reported having fewer emotionally satisfying consistent supports from relatives, but those who had physical illnesses reported more supports from relatives. The authors conclude that although having fewer key supports may contribute to dysphoria, having a physical illness may mobilize meaningful support. They suggest that social supports and health outcomes be carefully defined so that possible differential relationships between them can be understood more specifically.

Treatment costs and use of community mental health services for schizophrenia by age cohorts.

OBJECTIVE: Research on schizophrenia has tended to ignore patterns and costs of mental health service use in late life. The present study examined the types of mental health services used and their costs for several age-defined cohorts in a large community mental health system. METHOD: The data covered all users of the mental health system included in the San Diego county billing information system in fiscal years 1986 and 1990. Community mental health service use and codes were modeled as a function of patient demographic characteristics, diagnosis, and age. The patients were grouped into the following age categories: 18-29, 30-44, 45-54, 55-64, 65-74, and > or = 75 years of age. RESULTS: The total costs for schizophrenia were higher than those for other psychiatric disorders, and they were also age dependent. In both fiscal years, the costs of schizophrenia were higher for the youngest and oldest cohorts than for the patients in the 30-65-year range. CONCLUSIONS: The economic burden of late-life schizophrenia to the public mental health system is at least as high as that of schizophrenia in younger adults.

Direct assessment of functional status in older patients with schizophrenia.

OBJECTIVE: There has been a growing trend in medicine to evaluate the impact of illness on functional abilities. Such studies typically rely on the patient's or caregiver's report. The goal of this study was to assess directly the functional capacity of psychiatric patients, especially older ones. METHOD: The subjects were 55 outpatients with schizophrenia and 72 normal persons ranging in age from 45 to 86 years. The subjects were administered the Direct Assessment of Functional Status Scale, which assess behaviour during simulated daily activity tasks in the areas of time orientation, communication, transportation, finance, shopping, grooming, and eating. RESULTS: The patients with schizophrenia had significantly greater disability than the normal subjects according to total scale scores as well as the communication, transportation, finance, and shopping subscale scores. Global cognitive status was the best predictor of total scale score. CONCLUSIONS: The Direct Assessment of Functional Status Scale is a promising instrument for functional assessment in outpatients with schizophrenia.

Depressive symptoms in schizophrenia.

OBJECTIVE: The authors assessed the presence and severity of depressive symptoms, as well as their associations with other clinical measures, in a group of mid- to late-life patients with schizophrenia who were not in a major depressive episode or diagnosed with schizoaffective disorder. METHOD: Sixty outpatients with schizophrenia between the ages of 45 and 79 years and 60 normal comparison subjects without major neuropsychiatric disorders, proportionally matched for age and gender, were studied. Depressive symptoms were rated primarily with the Hamilton Depression Rating Scale. Standardized instruments were also used to measure global psychopathology, positive and negative symptoms, abnormalities of movement, and global cognitive status. RESULTS: Depressive symptoms were more frequent and more severe in schizophrenic patients than in normal comparison subjects; 20% of the women with schizophrenia had a Hamilton depression scale score of 17 or more. Severity of depressive symptoms correlated with that of positive symptoms but not with age, gender, negative symptoms, extrapyramidal symptoms, or neuroleptic dose. CONCLUSIONS: Depressive symptoms are common in older patients with schizophrenia. They may be an independent, core component of the disorder or, alternatively, may be a by-product of severe psychotic symptoms.

Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity.

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.

Adult heart disease prevention in childhood: a national survey of pediatricians' practices and attitudes.

There is controversy about the role of pediatric care givers in reducing presumed risk factors for cardiovascular diseases in children. A national mail survey of 2,000 pediatricians was designed to determine the attitudes, current practices, and knowledge among primary care pediatricians regarding these risks. The response rate was 60% (779 primary care pediatricians). Responses indicated that a majority of pediatricians take a family history of cardiovascular diseases, assess BP, recommend exercise to school-aged children, and advise patients and parents against smoking. Few pediatricians felt confident in their ability to affect change in patient life-styles. There was a relatively low level of provision of dietary advice, and most pediatricians do not measure serum cholesterol levels, except in high-risk older children. A substantial minority do not discuss smoking, even with adolescents. Practices and attitudes varied with the age of the patient. Obesity was the topic most frequently chosen for continuing medical education. Older pediatricians were most likely to advocate and practice risk reduction in children. Attitudes and reported practices also varied by gender and geographic location of the pediatrician as well as the ethnic composition of the practice. Implications for continuing medical education are discussed.

Association of depressive symptoms with worse functioning in schizophrenia: a study in older outpatients.

BACKGROUND: Subsyndromal depressive symptoms are highly prevalent and associated with substantial impairments of daily function in the general population. Depressive symptoms are common in schizophrenia. However, few studies have examined the relationship of functioning and well-being to the presence of depressive symptoms in schizophrenia. METHOD: 202 middle-aged or elderly outpatients with schizophrenia (DSM-III-R or DSM-IV criteria) were categorized by severity of depressive symptoms on the Hamilton Rating Scale for Depression (HAM-D) using previously validated cutoff points, i.e., HAM-D total score < or = 6 (low), from 7 to 16 (medium), and > or = 17 (high). We also assessed severity of positive and negative symptoms, movement disorders, neurocognitive performance, daily functioning, and health-related quality of well-being with standardized measures. RESULTS: A total of 11.4% of patients had HAM-D scores > or = 17, and 56.4% had HAM-D scores from 7 to 16. Even after adjusting for severity of other psychopathology, patients with more severe depressive symptoms had significantly worse everyday functioning (p < .02), except for physical functioning, and health-related quality of well-being (r = -.365, p < .001) than did those with lower HAM-D scores. These differences were unrelated to those in demographics, extrapyramidal symptoms, tardive dyskinesia, neurocognitive performance, or number of physical illnesses. CONCLUSION: The results suggest the importance of evaluating schizophrenia patients for the presence of depressive symptoms. Effectiveness of adjunct treatment of depressive symptoms with antidepressants and psychosocial management in improving functioning of schizophrenia patients deserves further study.

Neuroleptic dose reduction in older psychotic patients.

We conducted a non-randomized, rater-blind study to safely determine the lowest effective neuroleptic dosage in older psychotic patients and to evaluate the clinical, neuropsychological, and psychosocial effects of neuroleptic dosage reduction. Twenty-seven carefully selected patients with schizophrenia and related psychotic disorders over the age of 45 had their dosage tapered by 25% each month to determine their lowest effective dosage. These patients were compared with patients similar in age, gender, and education who were currently off neuroleptics (n = 19) or maintained on neuroleptics (n = 22). All groups were followed for 11 months. Over the follow-up period, 29% of patients in the taper group, 8% of neuroleptic-free patients, and 0% of patients in the maintenance group experienced some increase in psychopathology, although there was no significant change in mean PANSS score in any group, and no patient required hospitalization. Patients in the taper group were maintained on approximately 60% of their original neuroleptic dosage after restabilization. Extrapyramidal symptoms continued to improve over time in the taper group. Neuropsychological testing did not change significantly over time except for those in the taper group who experienced a decrease in memory-retention on the Hopkins Verbal Learning Test and a significant improvement in digit vigilance and Stroop Interference Index. Carefully selected middle-aged and elderly psychotic patients can have their neuroleptic medications reduced without a significant change in psychopathology. Extrapyramidal symptoms may continue to improve gradually over time. The impact on cognition functioning needs further investigation.

Social skills performance assessment among older patients with schizophrenia.

OBJECTIVE: Social functioning is an important outcome dimension in schizophrenia. Measures of social skills frequently rely on self-report, and most measures which directly assess social functioning are time consuming. Here we describe a brief performance-based measure, the Social Skills Performance Assessment (SSPA), modified from an instrument published by Bellack et al. (Bellack, A., Morrison, R., Wixted, J., Mueser, K., 1990. An analysis of social competence in schizophrenia. Br. J. Psychiatry 156, 809--818). METHOD: 83 middle-aged and elderly patients with schizophrenia or schizoaffective disorder, and 52 normal comparison subjects (NCs) were rated on two standardized role plays, one requiring introduction to a stranger and another requiring assertive behavior with their landlord. Ratings in eight areas ranging from 'social appropriateness' to 'grooming' were made. RESULTS: SSPA required about 12 min to complete both role play and ratings, and had excellent interrater reliability, and good test-retest reliability. Patients demonstrated significantly greater disability in all areas of social functioning compared with NCs. Social performance was related to severity of negative symptoms and cognitive deficits, but not that of positive or depressive symptoms. SSPA scores were significantly correlated with health-related quality of well-being and observed performance on activities of daily living, but not to a self-reported measure of social functioning. CONCLUSION: The SSPA is a reliable and useful instrument. Direct assessment of social skills may provide a more accurate picture of functioning than self-report measures among patients who frequently lack insight into their own behavior.

Self-reported social functioning among older patients with schizophrenia.

The purpose of this study was to evaluate the utility of a self-report measure of social functioning as an outcome measure for older schizophrenia patients. Sixty-five schizophrenia patients and 39 healthy controls, ranging in age from 45 to 81 years, were evaluated using a modified Social Adjustment Scale (SAS-M), Scales for Assessment of Positive and Negative Symptoms, Depression Subscale of the Brief Symptom Inventory, Mini-Mental State Examination, Dementia Rating Scale, measures of social support, and measures of background variables. Compared with controls, fewer patients with schizophrenia engaged in social roles, were married, were parents, or held jobs. Moreover, patients were more impaired in overall functioning, specifically in the domains of social/leisure, extended family, and marital roles than controls. Impairments in most roles were correlated with greater severity of symptoms, but not with degree of cognitive impairment, social environment, or background characteristics. The SAS-M is a useful addition to psychosocial batteries; however, the self-report format may not reflect others' perception of functioning.

Aggregation of dietary calories, fats, and sodium in Mexican-American and Anglo families.

There seems to be a consensus that family influences on dietary habits are important, but few studies have addressed this issue directly. To clarify inconsistent findings, we studied the aggregation of dietary fats, sodium, and calories in 95 Anglo and 111 Mexican-American families. Their diet was determined by 24-hour recall, a three-day food record, and a food frequency questionnaire, along with a measure of the urinary sodium-potassium ratio. There was evidence of moderate aggregation of all dietary variables in both ethnic groups. In Anglo families, spouse-spouse, but not sibling-sibling, correlations tended to be significant. The diets of the younger children, but not the older children, were related to their parents' diets. In Mexican-American families, both spouse-spouse and sibling-sibling correlations tended to be significant. The mothers' diets were more highly correlated with the children's diets than were the fathers'.

Predictors of dietary change in Mexican American families participating in a health behavior change program.

Previous research indicates that Mexican Americans have dietary patterns related to cardiovascular disease risk factors. Research on health beliefs in this ethnic group suggests that Mexican Americans may be less amenable to interventions based on cognitive-behavioral change models. Our study derives from the experience in a community trial, the San Diego Family Health Project, in which Mexican American families were recruited for a structured heart health intervention program. We examined correlations between one-year dietary change scores (three-day sodium, three-day fat, 24-hour sodium, 24-hour fat) and a set of predictor variables derived from social learning theory. Both adults and children had lower intake scores after the intervention, except for children's 24-hour sodium scores. Our correlational analysis found only weak and somewhat inconsistent relationships between theoretically based predictor and outcome variables for adults. The children's results showed statistically significant correlations between two theoretical variables (self-efficacy and supporting others' dietary change) and three-day fat and 24-hour sodium intake. We discuss the implications for cardiovascular disease risk reduction interventions with Mexican Americans.

Recruitment issues, health habits, and the decision to participate in a health promotion program.

To understand the external validity of experimental studies, it is important to estimate the extent to which the participants are representative of the general population. This paper describes recruitment methods and considers the representativeness of participants in the San Diego Family Health Project. The study was designed to experimentally evaluate the effectiveness of a family-based behavior change intervention in Anglo and Mexican-American families. Initial contact with the families was made through a household health survey that was sent home with all fifth- and sixth-grade children in 12 participating elementary schools. The survey asked about a variety of demographic characteristics, dietary habits, and physical activity habits. Parents were also asked if they were interested in participating in the project. Respondents were classified by level of participation into one of three groups: not interested, expressed initial interest but did not attend the recruitment meeting, and volunteered to participate. Level of participation was the independent variable in the analyses. In separate analyses for Anglo and Mexican-American responders, our data suggested many similarities and a few differences among participant groups. The differences that were observed suggest that participants may already have healthier diets than nonparticipants, although only one of four dietary variables differed by participation status in each ethnic group. The external validity of these data and general recruitment issues are discussed.