Characterizing cannabis use in a sample of adults with multiple sclerosis and chronic pain: An observational study.

BACKGROUND: Although cannabis has become an increasingly common method for pain management among people with multiple sclerosis (PwMS), there is a dearth of knowledge regarding the types of cannabis products used as well as the characteristics of cannabis users. The current study aimed to (1) describe the prevalence of cannabis use and the routes of administration of cannabis products in adults with an existing chronic pain condition and MS, (2) to examine differences in demographic and disease-related variables between cannabis users and non-users, and (3) to examine differences between cannabis users and non-users in pain-related variables, including pain intensity, pain interference, neuropathic pain, pain medication use, and pain-related coping. METHODS: Secondary analysis of baseline data from participants with multiple sclerosis (MS) and chronic pain (N = 242) enrolled in an RCT comparing mindfulness-based cognitive therapy (MBCT), cognitive-behavioral therapy (CBT), and usual care for chronic pain. Statistical methods included t-tests, Mann-Whitney tests, chi-square tests, and Fisher's exact tests to assess for differences in demographic, disease-related, and pain-related variables between cannabis users and non-users. RESULTS: Of the 242 participants included in the sample, 65 (27%) reported the use of cannabis for pain management. The most common route of administration was oil/tincture (reported by 42% of cannabis users), followed by vaped (22%) and edible (17%) products. Cannabis users were slightly younger than non-users (Medage 51.0 vs 55.0, p = .019) and reported higher median pain intensity scores (6.0 vs 5.0, p = .022), higher median pain interference scores (5.9 vs 5.4, p = .027), and higher median levels of neuropathic pain (20.0 vs 16.0, p = .001). CONCLUSIONS: The current study identified factors that may intersect with cannabis use for pain management and adds to our current knowledge of the types of cannabis products used by PwMS. Future research should continue to investigate trends in cannabis use for pain management, especially as the legality and availability of products continue to shift. Additionally, longitudinal studies are needed to examine the effects of cannabis use on pain-related outcomes over time.

Surveillance of long-term complications after treatment of adult brain tumor survivors-review and evidence-based recommendations.

As a result of treatment and diagnosis, adults with primary or metastatic brain tumors experience comorbidities that impacts their health and well-being. The Children's Oncology Group has guideline recommendations for childhood survivors of brain tumors; however, guidelines for monitoring long-term sequela among adult brain tumor survivors are lacking. The purpose of this review is to present the screening recommendations for the long-term complications after brain tumor treatment from a multidisciplinary panel of healthcare professionals. Chronic complications identified include cognitive dysfunction, vasculopathy, endocrinopathy, ophthalmic, ototoxicity, physical disability, sleep disturbance, mood disorder, unemployment, financial toxicity, and secondary malignancy. We invited specialists across disciplines to perform a literature search and provide expert recommendations for surveillance for long-term complications for adult brain tumor survivors. The Brain Tumor Center Survivorship Committee recommends routine screening using laboratory testing, subjective assessment of symptoms, and objective evaluations to appropriately monitor the complications of brain tumor treatments. Effective monitoring and treatment should involve collaboration with primary care providers and may require referral to other specialties and support services to provide patient-centered care during neuro-oncology survivorship. Further research is necessary to document the incidence and prevalence of medical complications as well as evaluate the efficacy of screening and neuro-oncology survivorship programs.

A comparison of anxiety symptoms and correlates of anxiety in people with progressive and relapsing-remitting multiple sclerosis.

BACKGROUND: Anxiety appears to be more prevalent in people with multiple sclerosis (MS) than in the general population, though it is unclear if anxiety varies by MS disease course. There are experiences unique to each disease course that might increase the likelihood of anxiety. Additionally, the majority of research in MS has focused on people with relapsing-remitting MS (RRMS), while the experiences of people with progressive forms of MS are understudied. This study examined anxiety in people with progressive MS (PMS) and examined group differences in anxiety compared to people with RRMS, and assessed unique and common correlates of anxiety in people with PMS and RRMS. METHODS: Secondary analysis of data from the fourth survey in a longitudinal study of quality of life in people with physical disabilities. The current study included a subset of participants with MS. Anxiety level was measured by the 4-item Patient-Reported Outcomes Measurement Information System - Anxiety Short Form T-score. T-test and chi-square analyses were used to compare groups. Correlates of anxiety were tested by examining the interaction of MS subtype (PMS and RRMS) and each potential correlate in multiple regression models with bootstrapping. RESULTS: Participants were 464 adults with MS (PMS n = 183; RRMS n = 281) who were predominately female, non-Hispanic white, and not employed with a mean age of 56.9 ± 10.3 years and disease duration of 17.5 ± 9.3 years. On average, participants with PMS reported anxiety symptoms (50.6 ± 8.6) that were comparable to those in the United States general population and statistically lower than participants with RRMS (52.8 ± 9.5; p = .01). Across MS courses, common factors associated with greater anxiety symptoms were shorter disease duration, lower household income, greater speech and/or swallowing problems, and current smoking (tobacco), adjusted R2 = .19, F(4, 391) = 22.68, p < .001. There was no evidence of unique correlates of anxiety symptoms in participants with either MS course. CONCLUSIONS: In this community sample, people with MS, regardless of disease course, reported similar levels of anxiety to the United States general population. This is inconsistent with prior literature that largely involves clinical samples, suggesting a need for further research with community samples of individuals with MS. This discrepancy may also be due to measurement differences between studies (e.g., screen versus symptom measures). Participants with RRMS reported greater average anxiety compared to those with PMS. This statistically significant difference was small and not clinically significant, indicating the need for further examination and replication. Overall, the findings highlight the wide heterogeneity of anxiety presentation within people with MS and identify potential factors to improve conceptualization and treatment of anxiety in this population. Further research is needed with community and clinical samples to understand anxiety in MS as well as risk and protective factors to improve conceptualization and treatment of anxiety in this population.

Human-centered design methods to achieve preparation phase goals in the multiphase optimization strategy framework.

Background: The public health impact of behavioral and biobehavioral interventions to prevent and treat mental health and substance use problems hinges on developing methods to strategically maximize their effectiveness, affordability, scalability, and efficiency. Methods: The multiphase optimization strategy (MOST) is an innovative, principled framework that guides the development of multicomponent interventions. Each phase of MOST (Preparation, Optimization, Evaluation) has explicit goals and a range of appropriate research methods to achieve them. Methods for attaining Optimization and Evaluation phase goals are well-developed. However, methods used in the Preparation phase are often highly researcher-specific, and concrete ways to achieve Preparation phase goals are a priority area for further development. Results: We propose that the discover, design, build, and test (DDBT) framework provides a theory-driven and methods-rich roadmap for achieving the goals of the Preparation phase of MOST, including specifying the conceptual model, identifying and testing candidate intervention components, and defining the optimization objective. The DDBT framework capitalizes on strategies from the field of human-centered design and implementation science to drive its data collection methods. Conclusions: MOST and DDBT share many conceptual features, including an explicit focus on implementation determinants, being iterative and flexible, and designing interventions for the greatest public health impact. The proposed synthesized DDBT/MOST approach integrates DDBT into the Preparation phase of MOST thereby providing a framework for rigorous and efficient intervention development research to bolster the success of intervention optimization. Plain Language Summary: 1. What is already known about the topic? Optimizing behavioral interventions to balance effectiveness with affordability, scalability, and efficiency requires a significant investment in intervention development.2. What does this paper add? This paper provides a structured approach to integrating human-centered design principles into the Preparation phase of the multiphase optimization strategy (MOST).3. What are the implications for practice, research, or policy? The proposed synthesized model provides a framework for rigorous and efficient intervention development research in the Preparation phase of MOST that will ensure the success of intervention optimization and contribute to improving public health impact of mental health and substance use interventions.

Moderators of Improvements in Fatigue Impact After a Self-management Intervention in Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial.

ABSTRACT: Fatigue is one of the most common and disabling symptoms of multiple sclerosis. A recent randomized controlled trial comparing a fatigue self-management program and a general multiple sclerosis education program found that both programs improved fatigue in participants with multiple sclerosis. Participants were randomized to a self-management program (fatigue: take control, n = 109) or a multiple sclerosis education program (multiple sclerosis: take control, n = 109). This secondary analysis of that trial used multilevel moderation analysis to examine moderators of treatment-related effects on fatigue (Modified Fatigue Impact Scale) from baseline through the 6-mo follow-up. The following potential treatment moderators were examined: age, sex, cohabitation/marital status, and baseline levels of self-efficacy, depression symptoms, and sleep quality. Cohabitation status (living with or without a spouse/partner) interacted with intervention group and time to predict fatigue impact (P = 0.04). Fatigue: take control participants who lived with a spouse/partner showed a marginal effect in greater rate of improvement in fatigue compared with those who lived alone (P = 0.08). However, rates of improvement in fatigue in multiple sclerosis: take control participants were similar in those living with or without a spouse/partner. These findings suggest that living with a spouse or partner may facilitate benefit from self-management interventions for multiple sclerosis-related fatigue. Future research should investigate the contribution of supportive others in self-management of fatigue in multiple sclerosis.

Outdoor Adventure Programs for Persons with Multiple Sclerosis: A Review and Agenda for Future Research.

Persons with multiple sclerosis (MS) often experience myriad symptoms that affect functioning and quality of life (QOL). Although there are a growing number of nonpharmacologic interventions designed to improve symptom severity and interference and maximize QOL, these particular treatments are limited by barriers to accessibility and, at times, a poor patient-intervention fit. Thus, it is important to consider alternative or supplemental nonpharmacologic treatments for people with MS. Outdoor adventure programs-group-based outdoor adventures aimed at enhancing QOL and fostering personal growth-could be one such alternative or supplemental approach. This topical review provides an overview of outdoor adventure programs; explores the current literature on these types of programs for the general population and medical populations; examines how outdoor adventure programs could enhance mood, functioning, and QOL for individuals with MS; and suggests future directions for research on outdoor adventure programs tailored to persons with MS.

A controlled trial of two mind-body interventions for grief in widows and widowers.

Objective: Following bereavement, yearning and grief rumination are repetitive cognitive processes that can lead to disordered grief. Mindfulness training (MT) has been shown to reduce maladaptive repetitive thought. The current quasi-randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of MT for bereavement-related grief. Method: Ninety-five widow(er)s (Mage = 67.5, 79% women, 98% White) between 6 months to 4 years post-loss were assigned to a 6-week MT intervention or a progressive muscle relaxation (PMR) intervention, or a wait-list condition. Outcome measures were grief severity (Revised Inventory of Complicated Grief), yearning (Yearning in Situations of Loss), rumination (Utrecht Grief Rumination Scale), and decentering (Experiences Questionnaire-Decentering) assessed at baseline, Weeks 2 and 4 of intervention, post-intervention, and 1-month post-intervention. Growth curve analysis examined group differences in rates of improvement in outcomes through follow-up and associations with improvement in grief severity. Results: The MT and PMR groups showed significant rates of decline in grief severity and yearning, though only the PMR group showed a greater rate of decline in grief severity than wait-list. All groups showed significant rates of decline in grief rumination. The PMR and wait-list groups showed significant rates of increase in decentering compared to the MT group. Conclusions: Results support the feasibility and acceptability of MT and PMR for widow(er)s as well as the preliminary efficacy of PMR for improving grief severity in widow(er)s compared to a wait-list control condition. With replication, PMR could be a standalone intervention for non-disordered grief or a component of treatment for disordered grief. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in correlates of fatigue between relapsing and progressive forms of multiple sclerosis.

BACKGROUND: Fatigue is one of the most prevalent and impactful symptoms for people with multiple sclerosis (MS). Yet, fatigue is less understood in progressive forms of MS, and few studies have explored the extent to which MS disease course is associated with fatigue. The current study aimed to (1) describe fatigue severity and fatigue interference (the extent to which fatigue interferes with individuals' physical, mental, and social activities) in people with progressive MS (primary progressive MS and secondary progressive MS); (2) compare fatigue severity and fatigue interference in people with progressive forms of MS to people with relapsing-remitting MS (RRMS); and (3) identify factors associated with fatigue severity and fatigue interference in people with progressive forms of MS and RRMS. METHODS: Secondary analysis of baseline data from participants with MS (N = 573; progressive forms of MS n = 142; RRMS n = 431) in a survey-based longitudinal study on healthy aging in people with a physical disability. Primary outcomes were average fatigue severity (0-10 Numerical Rating Scale), and fatigue interference (PROMIS Fatigue Short Form). Correlates were variables across the demographic and biopsychosocial domains, collected with validated self-reported measures. Statistical methods included t-test and chi-square analyses to compare fatigue severity and fatigue interference in people with progressive MS to those with RRMS, and multiple regression analyses to examine the association of variables with fatigue severity and fatigue interference. RESULTS: Participants with progressive forms of MS reported moderate to severe levels of average fatigue severity (5.9 ± 2.8) and elevated levels of fatigue interference (T-Score of 58.2 ± 7.9). There were no group differences between people with progressive MS and RRMS in average fatigue severity or fatigue interference. Common factors associated with greater fatigue severity were lower income, being unemployed, shorter disease duration, greater disability, and greater sleep disturbance. Common factors associated with fatigue interference were younger age, lower income, being unemployed, greater disability, lower alcohol consumption, being a smoker, and greater sleep disturbance. For those with progressive forms of MS, longer MS disease duration was associated with lower average fatigue severity (b = -0.08, t(532) = -3.69, p < .001) and having a college degree or higher was associated with higher fatigue interference (b = 2.84, t(520) = 2.23, p = .026). CONCLUSION: In this sample, fatigue severity and fatigue interference were similar for progressive forms of MS and RRMS. Future research should consider if interventions that work for fatigue management in people with relapsing forms of MS work similarly for people with progressive forms of MS.

Pain Intensity and Pain Interference in People With Progressive Multiple Sclerosis Compared With People With Relapsing-Remitting Multiple Sclerosis.

OBJECTIVE: To describe pain intensity and interference in people with progressive multiple sclerosis (MS), compare these with people with relapsing-remitting multiple sclerosis (RRMS), and identify common and unique factors associated with pain intensity in people with progressive MS and RRMS. DESIGN: Observational, cross-sectional analysis using baseline data from a longitudinal survey on quality of life in participants with MS. SETTING: Community. PARTICIPANTS: A total of 573 adults with MS (N=573; progressive MS, n=142; RRMS, n=431). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Average pain intensity was measured by an 11-point numeric rating scale, and pain interference was measured by the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form. RESULTS: Participants with progressive MS reported moderate average pain intensity (3.22±2.50) and elevated pain interference (T score of 55.55±9.13). They did not differ significantly from those with RRMS in average pain intensity or pain interference. Common factors associated with higher average pain intensity were more severe disability, lower education level, unemployment, and current smoking. In those with progressive MS, older age was associated with lower average pain intensity. CONCLUSIONS: Pain intensity and interference are similar across MS types. In addition to assessing and treating pain, it is important to screen for modifiable pain-related factors, such as smoking cessation, in this population.

Depressive Symptoms and Suicidal Ideation in Progressive Multiple Sclerosis Compared With Relapsing-Remitting Multiple Sclerosis: Results From a Cross-sectional Survey.

OBJECTIVES: To (1) describe depressive symptom severity and suicidal ideation (SI) in persons with progressive multiple sclerosis (MS); (2) compare depressive symptom severity and SI in persons with progressive MS and persons with relapsing-remitting multiple sclerosis (RRMS); and (3) identify common and unique risk factors for greater depressive symptom severity and SI in persons with progressive MS compared with individuals with RRMS. DESIGN: Observational, cross-sectional survey study. SETTING: Community. PARTICIPANTS: Adults with MS (N=573). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The dependent variables were depression symptoms and any SI measured by the Patient Health Questionnaire-9. Comparisons between groups used t tests and chi-square analyses, and risk factors were tested by examining the interaction of MS subtype (progressive MS and RRMS) and each risk factor in multiple regression models with bootstrapping. RESULTS: Persons with progressive MS did not differ from persons with RRMS in levels of depressive symptoms or SI. Both groups reported mild depressive symptoms and approximately 10% endorsed SI. Common risk factors for greater depressive symptom severity were younger age, greater disability, greater speech and swallowing problems, and lower household income. Common risk factors for SI were shorter disease duration, greater disability, and greater speech and swallowing problems. CONCLUSIONS: In this sample, there were no group differences between persons with progressive MS and persons with RRMS in depressive symptom severity and SI. Although both groups reported mild depressive symptoms on average, nearly 1 in 4 persons met criteria for probable major depression, which underscores the importance of screening for and treating depressive disorders in all persons with MS.

Early Treatment Improvements in Depression Are Associated With Overall Improvements in Fatigue Impact and Pain Interference in Adults With Multiple Sclerosis.

BACKGROUND: Depression, fatigue, and pain commonly co-occur in multiple sclerosis (MS) and are positively associated with one another. However, it is unclear whether treatment-related improvement in one of these symptoms is associated with improvements in the other two symptoms. PURPOSE: This study examined whether early improvements in depressive symptoms, fatigue impact, and pain interference during a multisymptom intervention in persons with MS were associated with overall improvements in the other two symptoms. METHODS: Secondary analysis of a randomized controlled trial in which both treatments improved depressive symptoms, fatigue, and pain interference. Adults with MS experiencing chronic pain, chronic fatigue, and/or moderate depressive symptoms (N = 154, 86% women) participated in an 8-week, telephone-delivered intervention: self-management (n = 69) or education (n = 85); intervention groups were combined for the current study. Outcome measures were depressive symptoms (PHQ-9), fatigue impact (Modified Fatigue Impact Scale), and pain interference (Brief Pain Inventory). Path analysis examined associations between pre-to-mid intervention improvement in one symptom (i.e., depression, fatigue, pain interference) and pre-to-post (overall) improvement in the other two symptoms. RESULTS: Early reduction in depressive symptoms was associated with an overall reduction in pain interference and fatigue impact (p's < .01). Early reduction in fatigue impact was associated with an overall reduction in depressive symptom severity (p = .04) but not pain interference. Early reduction in pain interference was not associated with reductions in fatigue impact or depressive symptoms. CONCLUSIONS: These findings suggest the potential importance of reducing depressive symptoms to overall improvement in fatigue and pain interference in persons with MS. CLINICAL TRIAL REGISTRATIONS: NCT00944190.

Wish you were here: The Dutch, German, and English Yearning in Situations of Loss Short Form.

OBJECTIVE(S): Yearning, a hallmark of grief disorders, relates to rumination and potentially to cognitive avoidance. We developed an 8-item short form of the only existing validated yearning measure, the Yearning in Situations of Loss Scale (YSL), to improve its validity and administration ease. METHOD: Cross-sectional surveys were conducted among bereaved Dutch (N = 313) and German (N = 235) community samples and an American treatment-seeking sample (N = 95). All samples completed the YSL, and community samples additionally measures of rumination, loss-related avoidance, complicated grief (CG), and depression. RESULTS: A one-factor model provided a good fit to the YSL Short Form (YSL-SF) in the community samples. A two-factor structure (cognitive and emotional yearning)best fitted the YSL-SF in the treatment-seeking sample. YSL-SF scores correlated positively with rumination, loss-related avoidance, and with CG symptoms whilst controlling for rumination and loss-related avoidance. CONCLUSION: The YSL-SF appears an easy-to-administer and valid measure of yearning after bereavement.

Behavioral Interventions in Multiple Sclerosis.

IMPORTANCE: Multiple sclerosis (MS) is a complex and unpredictable neurologic disease affecting nearly 1 million people in the US. People with MS commonly experience multiple physical and psychological symptoms such as depression, anxiety, stress, fatigue, and pain that impact functioning and quality of life. Subsequently, living with MS requires routine management of MS symptoms, adaptation to challenges, and engagement in health behaviors to promote well-being over time. OBSERVATIONS: There is considerable evidence that behavioral interventions that increase cognitive and/or behavioral skills to address the challenges of day-to-day life with MS can promote resilience and reduce overall distress associated with this chronic and unpredictable disease. Brief group-based cognitive-behavioral therapy (CBT) and CBT-based interventions (eg, self-management) have been shown to reduce symptoms of depression, anxiety, stress, fatigue, and pain in people with MS, including via telehealth delivery. Likewise, mindfulness-based interventions have been shown to improve depression, anxiety, stress, fatigue, and quality of life in people with MS. Behavioral interventions also have been shown to improve health behaviors such as physical activity and adherence to disease modifying therapies in MS. Unlike other treatment options, behavioral interventions can be delivered in various formats (eg, in-person, telehealth), are time-limited, and cause few (if any) undesirable systemic side effects. CONCLUSIONS: Behavioral intervention is an integral component of interprofessional care and key aspect of living well with MS.

Recruitment and retention in clinical and experimental bereavement research: Lessons learned from creating a research registry.

A small body of research investigates recruitment and retention of bereaved people in experimental and intervention research. The present study compares the effectiveness of different recruitment strategies implemented by a grief laboratory at a large state university in order to optimize recruitment efforts. The most effective method is letters sent to bereaved community members identified through online newspaper obituaries. Despite a small overall response rate, the large population from which to sample provides continuous accrual every month. Other methods include electronic/print media, community institution referrals, word of mouth and community outreach. Best practices for recruitment and retention are recommended.

A Systematic Review of the Association Between Bereavement and Biomarkers of Immune Function.

OBJECTIVE: Bereavement is associated with increased risk for morbidity and all-cause mortality across epidemiological, meta-analytic, and case-control studies. The body of research examining the association between bereavement and immune function, beginning in 1977, has yet to be reviewed. The current systematic review clarifies these findings, identifies limitations of the diverse literature, and suggests a model and directions for future research. METHODS: The PRISMA guidelines for systematic reviews were used to synthesize 41 years of research. Compared with a meta-analysis, a systematic review is appropriate given the heterogeneous nature of the studies. We used the National Heart, Lung, and Blood Institute Study Quality Assessment Tool to assess the quality of select studies. RESULTS: Thirty-three publications met inclusion criteria. Most studies support the association between bereavement and maladaptive changes in immune parameters in adults, with mixed findings on bereavement-related changes in cellular immunity. A handful of recent, good-quality studies show bereaved people demonstrate higher levels of systemic inflammation, maladaptive immune cell gene expression, and lower antibody response to vaccination compared with nonbereaved controls. Individual differences in psychological response to bereavement (e.g., depression, grief) seem to influence the association between bereavement and immune function. CONCLUSIONS: Research examining the association between bereavement and biomarkers of immune function is heterogeneous in methods and quality. Despite these limitations, there is evidence supporting maladaptive changes in immune function after bereavement. The research area would benefit from longitudinal research with larger sample sizes, advanced immunological methods, and incorporating measures of psychological responses to bereavement. The field is poised to refine and scale up its investigation of this common and important phenomenon.

New and Future Directions in Integrative Medicine Research Methods with a Focus on Aging Populations: A Review.

This review discusses existing and developing state-of-the-art noninvasive methods for quantifying the effects of integrative medicine (IM) in aging populations. The medical conditions of elderly patients are often more complex than those of younger adults, making the multifaceted approach of IM particularly suitable for aging populations. However, because IM interventions are multidimensional, it has been difficult to examine their effectiveness and mechanisms of action. Optimal assessment of IM intervention effects in the elderly should include a multifaceted approach, utilizing advanced analytic methods to integrate psychological, behavioral, physiological, and biomolecular measures of a patient's response to IM treatment. Research is presented describing methods for collecting and analyzing psychological data; wearable unobtrusive devices for monitoring heart rate variability, activity and other behavioral responses in real time; immunochemical methods for noninvasive molecular biomarker analysis, and considerations and analytical approaches for the integration of these measures. The combination of methods and devices presented in this review will provide new approaches for evaluating the effects of IM interventions in real-life ambulatory settings of older adults, and will extend the concept of mobile health to the domains of IM and healthy aging.

Absent but Not Gone: Interdependence in Couples' Quality of Life Persists After a Partner's Death.

Spouses influence each other's psychological functioning and quality of life. To explore whether this interdependence continues after a person becomes widowed, we tested whether deceased spouses' characteristics were associated with their widowed partners' later quality of life using couples drawn from a multinational sample of aging adults. Independent subsamples (ns = 221 and 325) were assessed before and after a spouse's death. Regressions revealed that deceased partners' quality of life prior to their death positively predicted their spouses' quality of life after the partners' death, even when we controlled for spouses' prior quality of life to account for environmental factors shared within couples. Further, widowed participants' quality of life was lower than nonwidowed couples' 2 years before and after their partners' death, but was equivalent 4 years prior. Finally, the strength of the association between partners' earlier quality of life and participants' later quality of life did not differ between widowed and nonwidowed participants. These findings suggest that interdependence in quality of life continues after one's partner has passed away.