Neorecovery: A Critical Analysis of the Relationship between Neoliberalism and the Recovery Movement.

"Neorecovery" is a portmanteau used to describe the distortions that neoliberalism engendered in the original recovery philosophy. I describe how neoliberalism as an economic model acted externally to the recovery movement to preclude opportunities to implement a wide range of innovative mental health approaches and to curtail safety net and social justice policies for persons with severe mental illness. In addition, I illustrate how the neoliberalism philosophy acted internally by inducing the recovery movement to adopt an individual-focused ethos that minimized the impact of broader social structures that affect well-being and opportunities for self-realization. Recovery's potentially radical transformative vision can only be achieved by seriously acknowledging the social and political structures that underlie the mental health system and their relationship to the broader society, and ultimately, altering them so that people experiencing severe mental illness can truly flourish.

The Relationships between Caregiver Burden, Physical Frailty, Race, Behavioral and Psychological Symptoms (BPSD), and Other Associated Variables: An Exploratory Study.

Background and Objectives: For persons with dementia, the relationships between caregiver burden, physical frailty, race, behavioral and psychological symptoms (BPSD), and other associated variables are poorly understood. Only one prior study examined the relationships among these variables but did not include race, which is an important social determinant of health outcomes in the United States. To examine these interactions, we conducted a cross-sectional exploratory study based on a model by Sugimoto and colleagues. Materials and Methods: The sample comprised 85 patient-caregiver dyads (58% White) seen in four centers in diverse regions of New York State. All patients met DSM5 criteria for a major neurocognitive disorder, had a Clinical Dementia Rating sum score of ≥3, and Mini-Mental State Examination (MMSE) score of 10 to 26. Other measures included the SHARE-Frailty Instrument(FI), the Neuropsychiatric Inventory (NPI) to assess BPSD, Zarit's Caregiver Burden Interview (CBI), Lawton's Activities of Daily Living (ADL) Scale, the MMSE, the Cumulative Illness Rating Scale for Geriatrics (CIRSG), age, and gender. Results: In our sample, 59% met the criteria for prefrail/subsyndromal or frail/syndromal (SSF) on the SHARE-FI. SSF had significant direct effects on the NPI and significant indirect effects on the CBI mediated through the NPI; the NPI had significant direct effects on the CBI. Race (White) had significant direct effects on the CBI (higher) and SSF (lower) but did not have significant indirect effects on the CBI. MMSE, ADL, and CIRSG were not significantly associated with the NPI or the CBI. Conclusions: Our analysis demonstrated that frailty, race, BPSD, and caregiver burden may directly or indirectly influence one another, and therefore should be considered essential elements of dementia assessment, care, and research. These results must be viewed as provisional and should be replicated longitudinally with larger samples.

Social Networks and Residential Status in Community-Dwelling Older Adults With Schizophrenia: Compensation by Reconfiguration?

OBJECTIVE: To address the paucity of data on the structure and content of social networks of older adults with schizophrenia (OAS). METHODS: The OAS group comprised 249 persons aged 55 and older with early-onset schizophrenia living in supportive housing (SS; n = 151), independently (SI; n = 70), or with family (SF; n = 28). The community comparison (CC) group comprised 113 individuals. Social network analysis was used. Multinomial logistic regression with p ≤0.001 and p ≤0.05 was used for overall and pairwise comparisons, respectively. RESULTS: Each OAS subgroup had more total, nonkin, and formal linkages than the CC group. The SS and SI subgroups had fewer kin linkages than the CC group. The CC group had more confidants than the SS subgroup, more reliable linkages than the SS and SI subgroups, and more sustenance linkages than each of the OAS subgroups. Nearly everyone in the CC, SI, and SF subgroups had a confidant, a reliable contact, and a sustenance linkage; 33% of the SS subgroup had no confidants. The SS subgroup displayed more psychiatric symptoms than the SI and SF subgroups. There were no differences in loneliness or relationship satisfaction between the CC and the schizophrenia subgroups. CONCLUSION: Networks were expressed differentially across residential arrangements and differences may reflect dissimilarities in psychiatric functioning. OAS generally had ample levels of companionship and emotional and instrumental support, often comparable to their age peers. Whereas social networks typically decline at illness onset and may be predominantly family-focused, later life may be a time of network reconfiguration and reconstitution.

Global cognitive trajectory patterns in Alzheimer's disease.

OBJECTIVES: The literature on Alzheimer's disease (AD) provides little data about long-term cognitive course trajectories. We identify global cognitive outcome trajectories and associated predictor variables that may inform clinical research and care. DESIGN: Data derived from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set were used to examine the cognitive course of persons with possible or probable AD, a Mini-Mental State Examination (MMSE) of ≥10, and complete annual assessments for 5 years. SETTING: Thirty-six Alzheimer's Disease Research Centers. PARTICIPANTS: Four hundred and fourteen persons. MEASUREMENTS: We used a hybrid approach comprising qualitative analysis of MMSE trajectory graphs that were operationalized empirically and binary logistic regression analyses to assess 19 variables' associations with each trajectory. MMSE scores of ±3 points or greater were considered clinically meaningful. RESULTS: Five distinct cognitive trajectories were identified: fast decliners (32.6%), slow decliners (30.7%), zigzag stable (15.9%), stable (15.9%), and improvers (4.8%). The decliner groups had three subtypes: curvilinear, zigzag, and late decline. The fast decliners were associated with female gender, lower baseline MMSE scores, a shorter illness duration, or receiving a cognitive enhancer. An early MMSE decline of ≥3 points predicted a worse outcome. A higher rate of traumatic brain injury, the absence of an ApoE ϵ4 allele, and male gender were the strongest predictors of favorable outcomes. CONCLUSIONS: Our hybrid approach revealed five distinct cognitive trajectories and a variegated pattern within the decliners and stable/improvers that was more consistent with real-world clinical experience than prior statistically modeled studies. Future investigations need to determine the consistency of the distribution of these categories across settings.

The utility of self-rated health in older adults with schizophrenia.

OBJECTIVES: Self-rated health is one of the most widely used measures in gerontology, but it has not been evaluated systematically in older adults with schizophrenia (OAS). Therefore, the aim of this study was to determine the utility of self-rated health in OAS by examining its influencing factors and contrasting these findings with a community comparison (CC) group. METHOD: We compared 249 community-dwelling persons aged 55 years and older having a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis of schizophrenia arising before age 45 years with a demographically similar group of 113 older adults in the general community. Using a modified version of Ocampo's model of self-rated health, we identified 12 predictor variables within 5 dimensions. RESULTS: There were no significant differences in self-health ratings between the OAS and the CC groups. Six of the 12 variables in the model significantly correlated with self-rated health in both groups. In linear regression analysis, three variables were significantly associated with self-rated health in both groups: Center for Epidemiological Studies-Depression score, number of physical disorders, and perception of self-health versus others. Self-rated health assessment was not associated with positive or negative symptoms or lack of awareness of mental illness. CONCLUSION: There was a striking similarity in the factors influencing self-rated health in the two groups. The findings were consistent with results of previous gerontological studies that self-rated health reflects elements of psychiatric and physical well-being, as well as perceptions of their age peers. Our results support the use of self-rated health as a legitimate clinical and research measure in OAS.

Recovery and Recovering in Older Adults with Schizophrenia: A 5-Tier Model.

RATIONALE: There are little recent data on clinical recovery in older adults with schizophrenia. This exploratory study uses an empirically measurable construct to address this issue. METHODS: From an original sample of 248 community-dwelling persons aged 55 and over with early-onset schizophrenia spectrum disorder, a subsample of 102 persons was reassessed at a mean of 52 months. Clinical recovery required meeting criteria for its two components: clinical remission and community integration. RESULTS: Prospective analysis generated a 5-tier taxonomy of recovery in which 12% remained persistently in clinical recovery at both baseline and follow-up (Tier 1) and 18% never met criteria of clinical recovery (Tier 5). The remaining 70% exhibited a variety of components of clinical recovery at baseline and follow-up (Tiers 2, 3, and 4). CONCLUSION: The findings generated a dynamic picture of recovery, with most persons being in varying states of "recovering." The 5-tier taxonomy of recovery adumbrated potential treatment strategies for each tier.

A Longitudinal Study of Illness Awareness in Older Adults With Schizophrenia.

OBJECTIVE: Impaired insight is common in schizophrenia and may be affected by changes that occur with aging. There have been a few nonprospective investigations of insight in older adults with schizophrenia (OAS). This study examines the temporal fluctuations that occur with insight-defined as "awareness of mental illness" (dichotomized into presence or absence)-along with associated factors that influence illness awareness (IA) in OAS. METHODS: The sample consisted of 103 persons derived from an initial sample of 250 community-dwelling persons aged 55 and over with early-onset schizophrenia spectrum disorder. Mean follow-up was 53 months. We examined 27 potential predictor variables of IA along with 5 covariates in bivariate analysis. The significant variables were then examined using multiple regression analyses. RESULTS: 23% of persons transitioned between presence and absence of IA, 62% had persistent IA, and 15% never had IA. At baseline, fewer negative symptoms (blunted affect), higher cognitive functioning (conceptualization), younger age, higher educational levels, and more physical disorders were associated significantly with higher rates of IA at follow-up. Baseline IA did not predict any variables at follow-up. CONCLUSION: IA is often unstable in later life, with nearly one-fourth of persons showing fluctuations. Although younger age predicted IA over time, other factors associated with aging, such as cognitive functioning and physical disorders, had additional independent effects on IA. The impact of IA on clinical and functional variables attenuated over time, suggesting that for many OAS, IA may have a limited role in enhancing long-term outcomes.

A Longitudinal Analysis of Quality of Life and Associated Factors in Older Adults with Schizophrenia Spectrum Disorder.

OBJECTIVES: Self-perceived quality of life (QOL) is an important outcome indicator in schizophrenia and a predictor of symptomatic and functional improvement. This study provides the first large scale longitudinal study of the fluctuations, predictors, and impact of QOL in older adults with schizophrenia spectrum disorder (SSD). METHODS: The sample consisted of 104 community-dwelling persons with SSD aged 55 and over (mean age: 61years) who developed the disorder prior to age 45. Mean follow-up was 52.5 months (range 12-116 months); 55% were men; 55% were white. We identified 22 potential predictor variables and used the Quality of Life Index (QLI) to assess QOL. RESULTS: There were no significant group differences in the QLI at baseline and follow-up. However, 33%, 24% and 43% of persons exhibited > 0.5 effect size increase or decrease, or no change, respectively. In multivariable analysis, there were 5 baseline predictors of QLI at follow-up: QLI, Center for Epidemiological Studies-Depression Scale (CES-D) scores, religiousness, perceived well-being versus others/past self, and time from initial interview. Baseline QLI predicted 5 variables at follow-up: the Positive and Negative Syndrome Scale (PANSS) anxiety score, PANSS positive score, CES-D score, insight, and perceived well-being versus others/past self. CONCLUSION: In many persons with SSD, QOL is not static in later life and one third improved their QOL. Effectively treating depressive symptoms and encouraging religious participation may improve QOL. QOL had two pivotal roles: As a relatively independent dynamic outcome measure and as a critical variable affecting clinical outcomes such as anxiety, depressive and positive symptoms.

A Longitudinal Study of the Outcome and Associated Factors of Subsyndromal and Syndromal Depression in Community-Dwelling Older Adults with Schizophrenia Spectrum Disorder.

OBJECTIVE: Studies examining depression in older adults with schizophrenia have been limited by cross-sectional data. This study examines longitudinal changes in depression, predictors of depression, and the impact of depression on clinical and psychosocial variables in this population. METHODS: The sample consisted of 104 community-dwelling persons with schizophrenia spectrum disorder aged 55 and over who developed the disorder before age 45. Mean follow-up was 54 months (range: 12-116 months), mean age was 61 years, 55% were men, and 55% were white. Presence of subsyndromal or syndromal depression (SSSD) was defined as scoring >7 on the Center for Epidemiologic Studies-Depression Scale (CES-D). RESULTS: There were no significant differences in SSSD rates between interviews (61% baseline; 54% follow-up); 44% of the sample had SSSD at both assessments, 30% did not have SSSD at either assessment, 16% went from SSSD to nondepression, and 10% went from nondepression to SSSD. Similarly, 20%, 27%, and 53% of the sample exhibited >0.5 effect size increase, decrease, or no change, respectively, in their CES-D scores between assessments. There were two significant time 1 predictors of SSSD at time 2: SSSD and greater number of psychotropic medications. SSSD at time 1 predicted having higher time 2 anxiety scores. CONCLUSION: Persistent ("core") depression occurs in about two-fifths of persons, 30% remain persistently nondepressed, and one-fourth may fluctuate between depression and nondepression. No association was found between depression and most predictor variables. This study supports recent findings that schizophrenia in later life is not a quiescent state or one of affective withdrawal.

Late-life psychosis: diagnosis and treatment.

Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the "six d's" of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.

Longitudinal study of remission among older adults with schizophrenia spectrum disorder.

OBJECTIVE: Although studies have found that as many as half of older community-dwelling adults with schizophrenia were in symptomatic remission, these findings had been based on cross-sectional data. This study examines longitudinal changes in symptom remission rates and predictors of remission. METHODS: The original sample consisted of 250 persons with schizophrenia spectrum disorders aged 55 and over living in New York City who developed the disorder before age 45. Data on 104 follow-up interviews are presented. Mean follow-up was 54 months (range: 12-116 months); mean age was 61 years, 55% were male, and 55% were white. A modified version of the Remission in Schizophrenia Working Group criteria was used for determining remission status. RESULTS: There was a nonsignificant decline in the percentage attaining remission (49% baseline, 40% follow-up); 25% were in remission at both assessments, 35% were not in remission at either assessment, 25% went from remission to nonremission, and 16% went from nonremission to remission. Four significant baseline predictors of remission were found at follow-up: higher community integration, greater number of entitlements, fewer psychotropic medications, and lower frequency of psychiatric services. Baseline remission status predicted having more total contacts at follow-up. CONCLUSION: Older adulthood is not necessarily a quiescent period, and there is considerable fluctuation in remission status. Two social variables-community integration and entitlements-predicted remission on follow-up, thus suggesting social interventions may be especially useful strategies for this population.

Characteristics of auditory hallucinations and associated factors in older adults with schizophrenia.

OBJECTIVE: To examine the characteristics of auditory verbal hallucinations and associated factors in older adults with schizophrenia. METHODS: One hundred ninety-eight persons aged 55 and older living in the community who had developed schizophrenia before age 45 years were assessed for the presence, topography, content, and subjective qualities of auditory hallucinations. George's social antecedent model of psychopathology was used to examine 17 predictor variables of auditory hallucinations. RESULTS: Thirty-two percent experienced auditory verbal hallucinations. More than half heard voices daily, heard good/pleasant voices, or had command hallucinations; 25% obeyed "bad" voices, whereas 87% obeyed "good" voices. There were no significant differences in depression and social functioning between persons judging their voices to be good versus bad. In logistic regression analysis, depressive symptoms, Positive and Negative Syndrome Scale delusion score (>2), and male gender were associated with auditory verbal hallucinations. CONCLUSION: Older adults with schizophrenia had a lower rate of auditory verbal hallucinations than had been reported previously for younger persons with schizophrenia. For most features of auditory verbal hallucinations, older adults had similar rates to younger persons. However, older adults were more apt to judge their voices as good and more likely to obey the good voices than those voices perceived as bad. From a clinical standpoint, this may be construed as a potentially useful coping strategy. However, subjective judgments about voices did not significantly affect mood or functioning, and the presence of auditory verbal hallucinations was associated with more depressive symptoms.

Prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder.

OBJECTIVE: To examine the prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder living in the community. METHODS: The sample consisted of a multiracial sample of 198 persons aged 55 and more with a schizophrenia spectrum disorder that developed the disorder before the age of 45; 39% and 61% lived independently and in supported community residences, respectively. George's Social Antecedent Model of Psychopathology was used to examine 16 predictor variables of negative symptoms, based on scores of 4 or more on any of the PANSS negative symptom items. RESULTS: Forty percent of the sample met the criteria for the presence of negative symptoms, and this decreased to 19% when potential secondary symptoms were excluded. In bivariate analysis, 10 variables were found to be significantly associated with the presence of negative symptoms, but when the model was tested in logistic regression analysis, only 3 variables retained significance: greater positive symptom scores (odds ratio [OR] = 1.26), lower cognitive scores (OR = 0.96), and fewer confidantes (OR = 0.80). CONCLUSION: Negative symptoms do not dominate the clinical picture in later life, and levels of negative symptoms appear to be no higher than in younger schizophrenia populations. The relative paucity of significant variables and their modest effect sizes suggest that treatment for negative symptoms in later life will depend largely on strategies directed specifically at the negative symptoms.

Interpersonal conflict strategies and their impact on positive symptom remission in persons aged 55 and older with schizophrenia spectrum disorders.

BACKGROUND: Although interpersonal interactions are thought to affect psychopathology in schizophrenia, there is a paucity of data about how older adults with schizophrenia manage interpersonal conflicts. This paper examines interpersonal conflict strategies and their impact on positive symptom remission in older adults with schizophrenia spectrum disorders. METHODS: The schizophrenia group consisted of 198 persons aged 55 years and over living in the community who developed schizophrenia before age 45. A community comparison group (n = 113) was recruited using randomly selected block-groups. Straus' Conflict Tactics Scale (CTS) was used to assess the ways that respondents handled interpersonal conflicts. RESULTS: Seven conflict management subscales were created based on a principal component analysis with equamax rotation of items from the CTS. The order of the frequency of the tactics that was used was similar for both the schizophrenia and community groups. Calm and Pray tactics were the most commonly used, and the Violent and Aggressive tactics were rarely utilized. In two separate logistic regression analysis, after controlling for confounding variables, positive symptom remission was found to be associated significantly with both the Calm and Pray subscales. CONCLUSIONS: The findings suggest that older persons with schizophrenia approximate normal distribution patterns of conflict management strategies and the most commonly used strategies are associated with positive symptom remission.

Frailty: A Multidimensional Biopsychosocial Syndrome.

The original conceptual landscape of frailty has evolved into a complex, multidimensional biopsychosocial syndrome. This has broadened the field to now include social and behavioral scientists and clinicians from a wide range of specialties. This article aims to provide an updated overview of this conceptual change by examining the emerging definitions of physical, cognitive, social, and psychological frailty; the tools used for diagnosis and assessment of these domains; the epidemiology of the domains; their pathogenesis, risk factors, and course; frameworks for prevention and treatment; and unresolved issues affecting the field.

The relationship between trauma and clinical outcome variables among older adults with schizophrenia spectrum disorders.

OBJECTIVE: Stressful and traumatic life events have been implicated in the etiology and persistence of symptoms in schizophrenia, but little is known about their impact in later life. This article contrasts lifetime trauma among older persons with schizophrenia with their age peers in the general population, and examines whether greater trauma is associated with higher rates of nonremission of positive and negative symptoms, depression, or anxiety symptoms in the schizophrenia group. METHODS: The schizophrenia group consisted of 198 community-dwelling persons age 55 and older who developed a schizophrenia spectrum disorder before age 45. A community comparison group (N = 113) was recruited using randomly selected block-groups. Using the Trauma and Victimization Scale, the frequency × severity of lifetime traumatic events scores were calculated. In the schizophrenia group, subjects were dichotomized into low and high trauma groups. RESULTS: As compared to the community group, the schizophrenia group scored significantly higher on the total score and on 6 of 11 items of the Trauma and Victimization Scale. The schizophrenia group had significantly more traumatic events before age 17. In logistic regression analysis, a high level of trauma accumulated across the lifespan in the schizophrenia group was associated only with non-remission of positive symptoms; however, the persistence of positive symptoms was not associated with a traumatic event prior to age 17. CONCLUSION: Early trauma may play some role in the development of schizophrenia, but it does not seem to have any special role in the persistence of positive symptoms in later life. Rather, accumulated stressors may be more relevant clinically. The findings suggest that it may be profitable to consider therapies that reduce the psychological impact of traumatic events.