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• Traditional approaches to disparities research have not fully considered how combinations of factors are associated with outcomes. • Using classification and regression Trees, we identified developmental disabilities, age, race and ethnicity, and utilization as top predictors of adherence/. • Top predictors of emergency department utilization included a history of injuries, anxiety and mood disorders, headache, back problems, and urinary tract infections. • Even when race and ethnicity did not appear as a top predictor of poor outcomes, there was variation in the clinical and social factors that contribute to poor adherence and high utilization. We used a machine learning approach to identify the combinations of factors that contribute to lower adherence and high emergency department (ED) utilization. Using Medicaid claims, we identified adherence to anti-seizure medications and the number of ED visits for people with epilepsy in a 2-year follow up period. We used three years of baseline data to identify demographics, disease severity and management, comorbidities, and county-level social factors. Using Classification and Regression Tree (CART) and random forest analyses we identified combinations of baseline factors that predicted lower adherence and ED visits. We further stratified these models by race and ethnicity. From 52,175 people with epilepsy, the CART model identified developmental disabilities, age, race and ethnicity, and utilization as top predictors of adherence. When stratified by race and ethnicity, there was variation in the combinations of comorbidities including developmental disabilities, hypertension, and psychiatric comorbidities. Our CART model for ED utilization included a primary split among those with previous injuries, followed by anxiety and mood disorders, headache, back problems, and urinary tract infections. When stratified by race and ethnicity we saw that for Black individuals headache was a top predictor of future ED utilization although this did not appear in other racial and ethnic groups. ASM adherence differed by race and ethnicity, with different combinations of comorbidities predicting lower adherence across racial and ethnic groups. While there were not differences in ED use across races and ethnicity, we observed different combinations of comorbidities that predicted high ED utilization. [ABSTRACT FROM AUTHOR]

Objective: Some individuals with bipolar disorder (BD) experience manic and depressive symptoms concurrently, but data are limited on symptom mixity in older age bipolar disorder (OABD). Using the Global Aging & Geriatric Experiments in Bipolar Disorder Database, we characterized mixity in OABD and associations with everyday function.Methods: The sample (n = 805), from 12 international studies, included cases with both mania and depression severity ratings at a single timepoint. Four mixity groups were created: asymptomatic (A), mixed (Mix), depressed only (Dep), and manic only (Man). Generalized linear mixed models used mixity group as the predictor variable; cohort was included as a random intercept. Everyday function was assessed with the Global Assessment of Functioning score.Results: Group proportions were Mix (69.6%; n = 560), followed by Dep (18.4%; n = 148), then A (7.8%; n = 63), then Man (4.2%; n= 34); levels of depression and mania were similar in Mix compared to Dep and Man, respectively. Everyday function was lowest in Mix, highest in A, and intermediate in Man and Dep. Within Mix, severity of depression was the main driver of worse functioning. Groups differed in years of education, with A higher than all others, but did not differ by age, gender, employment status, BD subtype, or age of onset.Conclusions: Mixed features predominate in a cross-sectional, global OABD sample and are associated with worse everyday function. Among those with mixed symptoms, functional status relates strongly to current depression severity. Future studies should include cognitive and other biological variables as well as longitudinal designs to allow for evaluation of causal effects. [ABSTRACT FROM AUTHOR]

Objectives: To compare the prevalence of physical morbidities among men and women with older adult bipolar disorder (OABD), and men with and without OABD.Methods: Cross-sectional analysis of the collaborative Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) database and non-OABD data from the Health in Men Study. OABD defined as bipolar disorder among adults aged greater than or equal to 50 years. Outcomes of interest were diseases affecting the cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal and endocrinological systems.Results: We examined 1407 participants with OABD aged 50-95 years, of whom 787 were women. More women than men showed evidence of morbidities affecting the respiratory, gastrointestinal, musculoskeletal and endocrinological systems. More men with than without OABD showed evidence of cardiovascular, renal and endocrinological diseases.Conclusion: GAGE-BD data showed that physical morbidities affect more women than men with OABD, and more men with than without OABD. The underlying reasons for these differences require clarification. [ABSTRACT FROM AUTHOR]

Objectives: To assess long-term safety and efficacy of deutetrabenazine in younger (<55 years) and older (≥55 years) adult participants with tardive dyskinesia (TD).Design: Three-year, single-arm, open-label extension (OLE) study enrolling participants who completed the 12-week, pivotal ARM-TD or AIM-TD studies.Setting: Seventy-six centers in the United States and Europe.Participants: A total of 337 participants with TD (119 younger and 218 older).Intervention: Deutetrabenazine was initiated at 12 mg/day and titrated once weekly by 6 mg/day using a response-driven dosing regimen until adequate dyskinesia control was reached or a clinically significant adverse event occurred.Measurements: This post hoc analysis assessed change and percent change from baseline in total motor Abnormal Involuntary Movement Scale (AIMS) score, response rates for ≥50% AIMS improvement, Clinical Global Impression of Change (CGIC), Patient Global Impression of Change (PGIC), and safety in younger and older participants with TD.Results: After 3 years of open-label treatment, mean deutetrabenazine dose was ∼39.5 mg/day in both groups. Mean±SE changes from baseline in total motor AIMS score were -6.7 ± 0.62 and -6.5 ± 0.47 in younger and older participants, respectively (percent changes: -61.4% ± 4.10% and -54.6% ± 3.01%); 76% of younger and 62% of older participants achieved ≥50% AIMS response. Most younger and older participants achieved treatment success per CGIC (67% and 76%) and PGIC (64% and 63%). Deutetrabenazine was generally well tolerated in both groups.Conclusions: Deutetrabenazine treatment was associated with sustained improvements in total motor AIMS score, treatment success, and improved quality of life, and was well tolerated in younger and older adults with TD in this 3-year OLE study. [ABSTRACT FROM AUTHOR]

Objective: Although 25% of people with bipolar disorder (BD) are over age 60, there is a dearth of research on older age bipolar disorder (OABD). This report describes an initial effort to create an integrated OABD database using the U.S. National Institute of Mental Health Data Archive (NDA). Goals were to: 1) combine data from three BD studies in the United States that included overlapping data elements; 2) investigate research questions related to aims of the original studies; and 3) take an important first step toward combining existing datasets relevant to aging and BD.Methods: Data were prepared and uploaded to the NDA, with a focus on data elements common to all studies. As appropriate, data were harmonized to select or collapse categories suitable for cross-walk analysis. Associations between age, BD symptoms, functioning, medication load, medication adherence, and medical comorbidities were assessed. The total sample comprised 451 individuals, mean age 57.7 (standard deviation: 13.1) years.Results: Medical comorbidity was not significantly associated with either age or functioning and there did not appear to be an association between medication load, comorbidity, age, and adherence. Men and African-Americans were significantly more likely to have poor adherence. Both BD mania and depression symptoms were associated with functioning, but this differed across studies.Conclusion: Despite limitations including heterogeneity in study design and samples and cross-sectional methodology, integrated datasets represent an opportunity to better understand how aging may impact the presentation and evolution of chronic mental health disorders across the lifespan. [ABSTRACT FROM AUTHOR]

As described in the DSM-5-TR, middle-aged and elderly individuals have an increased risk for tardive dyskinesia (TD), a persistent and potentially disabling movement disorder associated with exposure to antipsychotics and other dopamine receptor blocking agents. Valbenazine, a highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor, is the only FDA-approved TD medication with once-daily dosing and no requirements or cautions for dose adjustment in elderly patients (≥65 years). To further elucidate long-term TD outcomes in elderly patients, data from two valbenazine studies (KINECT 3-extension [K3] and KINECT 4 [K4]) were analyzed post hoc in participants who were ≥65 years old. The analyses were also conducted in participants who were ≥55 years old to capture information in those who may be considered middle-aged. K3 and K4 study participants received valbenazine (40 or 80 mg) once daily for 48 weeks. Data were pooled from the K3/K4 baseline visit and post-baseline visits (Week 8 [both studies], Week 12/16 [K4/K3], Week 24 [K4 only], Week 32/36 [K3/K4], and Week 48 [both studies]) and analyzed by age (≥55 yrs, ≥65 yrs). Analyses based on Abnormal Involuntary Movement Scale (AIMS) total score included: mean change from baseline to end of treatment, which was the primary efficacy endpoint in both studies; and treatment response, defined as ≥50% AIMS improvement from baseline. For the Clinical Global Impression of Change-Tardive Dyskinesia (CGI-TD) and Patient Global Impression of Change (PGIC), response was defined as a rating of "much improved" or "very much improved" (score ≤2). The pooled AIMS, CGI-TD, and PGIC data were analyzed descriptively with no imputation for missing values. Safety assessments included treatment-emergent adverse events (TEAEs) and psychiatric stability, as assessed using the following scales: Positive and Negative Syndrome Scale (PANSS) and Calgary Depression Scale for Schizophrenia (CDSS) in patients with schizophrenia/schizoaffective disorder; Young Mania Rating Scale (YMRS) and Montgomery-Åsberg Depression Rating Scale (MADRS) in patients with mood disorder. In both age groups, mean improvements in AIMS total score increased over time. At Week 8 (first pooled post-baseline visit) and Week 48 (end of treatment), mean score changes from baseline in elderly participants (≥65 yrs) were -4.5 and -8.8, respectively. The percentage of participants in this age group who met response thresholds were as follows: AIMS ≥50% improvement (40.0% [20/50] and 82.1% [23/28] for Weeks 8 and 48, respectively); CGI-TD ≤2 (33.3% [17/51] and 92.9% [26/28]); PGIC ≤2 (43.1% [22/51] and 85.7% [24/28]). Similar results were found in participants aged ≥55 yrs. Safety analyses indicated similar incidences between age groups for any TEAE (76.8% and 72.7% for ≥55 yrs [n=190] and ≥65 yrs [n=55], respectively) and serious TEAEs (20.5% and 18.2%). The percentage of participants who discontinued due to a TEAE increased with age (18.9% and 25.5%). Mean changes from baseline to Week 48 in psychiatric symptom scale scores were minimal, indicating maintenance of psychiatric stability in both age groups. Long-term treatment with once-daily valbenazine led to clinically meaningful reductions of TD symptoms in elderly patients with TD (≥65 yrs) and those who were middle-aged or elderly (≥55 yrs). After 48 weeks of valbenazine treatment, >80% of participants in the ≥65 yrs age group met rigorous thresholds of TD improvement, with similar results in the ≥55 yrs. age group. These results may help clinicians make treatment decisions for managing TD in older patients, including those who are middle-aged or elderly. Neurocrine Biosciences, Inc. [ABSTRACT FROM AUTHOR]

Stigma negatively affects individuals with cognitive impairment and dementia. This literature review examined the past decade (January 2004 to December 2015) of world-wide research on dementia-related stigma. Using standard systematic review methodology, original research reports were identified and assessed for inclusion based on defined criteria. Initial database searches yielded 516 articles. After removing duplicates and articles that did not fit inclusion criteria (419), 97 articles were reviewed, yielding a final total of 51 publications, mainly originating in the United States and Europe. Studies were assessed for date, geographic region, sample description, methodology, and key findings. Reports were evaluated on 1) how stigmatizing attitudes may present in various subgroups, including in racial or ethnic minorities; 2) stigma assessment tools; and 3) prospective or experimental approaches to assess or manage stigma. Stigma impedes help-seeking and treatment, and occurs broadly and world wide. Stigmatizing attitudes appear worse among those with limited disease knowledge, those with little contact with people with dementia, in men, in younger individuals, and in the context of ethnicity and culture. In some cases, healthcare providers may have stigmatizing attitudes. In research studies, there does not appear to be consensus on how to best evaluate stigma, and there are few evidence-based stigma reduction approaches. Given the projected increase in persons with dementia globally, there is a critical need for research that better identifies and measures stigma and tests new approaches that can reduce stigmatizing attitudes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and effectiveness of 6 months of treatment with lurasidone in older adults with a diagnosis of bipolar I depression.Design: Post-hoc analysis of a multicenter, 6-month, open-label extension study.Setting: Outpatient.Participants: Patients aged 55 to 75 years with a DSM-IV-TR diagnosis of bipolar I depression who had completed 6 weeks of double-blind, placebo-controlled treatment with either lurasidone monotherapy (1 study) or adjunctive therapy with lithium or valproate (2 studies).Intervention: Flexible doses of lurasidone, 20 to 120 mg/day, either as monotherapy, or adjunctive with lithium or valproate.Measurements: Effectiveness was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS; change from open-label-baseline to month-6, observed case analysis).Results: A total of 141 older adults entered the extension study (monotherapy, N = 55; 39%; adjunctive therapy, N = 86; 61%). At the end of 6 months of open-label treatment with lurasidone, as monotherapy or adjunctive therapy, minimal changes were observed in the older adult sample in mean weight (-1.0 kg and -0.4 kg, respectively); and median total cholesterol (-2.0 mg/dL and +6.0 md/dL, respectively), triglycerides (+2.5 mg/dL and +6.0 mg/dL, respectively), and HbA1c (0.0% and -0.1%, respectively). Patients treated with 6 months of lurasidone showed a mean improvement on the MADRS in both the monotherapy (-6.2) and adjunctive therapy (-6.7) groups.Conclusions: Results of these post-hoc analyses found that up to 7.5 months of lurasidone treatment for bipolar depression in older adults was associated with minimal effects on weight and metabolic parameters, with low rates of switching to hypomania or mania, and was well tolerated. The antidepressant effectiveness of lurasidone in this age group was maintained over the 6-month treatment period. [ABSTRACT FROM AUTHOR]

Objective To develop a deeper understanding of “how” a nurse led self-management intervention in a successful randomized controlled trial (RCT) for individuals with both serious mental illness (SMI) and diabetes (DM) influenced health outcomes and the lives of the participants. Methods In depth interviews, were conducted with a sample of 10 participants who received the self-management intervention in the RCT. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis, with an emphasis on dominant themes. Results The mean age of the respondents was 53.9 years (SD = 5.6); 6 (60%) were women and the mean level of education was 12.4 years (SD = 2.4). Transcript based analysis generated 3 major mechanisms of action that led to improved self-management of their SMI and DM: (Colton & Manderscheid, 2006) positive group experience, (Osborn et al., 2008) increased health knowledge, and (Newcomer, 2005) increased self- confidence. Conclusions Developing complex interventions for testing in RCTs of individuals with SMI and other comorbid conditions is of increasing importance in healthcare planning for this vulnerable population. Using qualitative methods to explore mechanisms of action underlying quantitative outcomes, can enrich our understanding of processes relevant for individuals with SMI and comorbid conditions. [ABSTRACT FROM AUTHOR]

Background: Previous research on Uganda's poststroke population revealed that their level of dietary salt knowledge did not lead to healthier consumption choices.Purpose: Identify barriers and motivators for healthy dietary behaviors and evaluate the understanding of widely accepted salt regulation mechanisms among poststroke patients in Uganda.Methods: Convergent parallel mixed methods triangulation design comprised a cross-sectional survey (n = 81) and 8 focus group discussions with 7-10 poststroke participants in each group. We assessed participant characteristics and obtained insights into their salt consumption attitudes, perceptions, and knowledge. Qualitative responses were analyzed using an inductive approach with thematic analytic procedures. Relationships between healthy dietary salt compliance, dietary salt knowledge, and participant characteristics were assessed using logistic regression analyses.Results: Healthy dietary salt consumption behaviors were associated with basic salt knowledge (P < .0001), but no association was found between compliance and salt disease-related knowledge (P = .314). Only 20% and 7% obtained health-related salt knowledge from their health facility and educational sources, respectively, whereas 44% obtained this information from media personalities; 92% of participants had no understanding of nutrition labels, and only 25% of the study population consumed potash-an inexpensive salt substitute that is both rich in potassium and low in sodium.Conclusion: One barrier to healthy dietary consumption choices among Uganda's stroke survivors is a lack of credible disease-related information. Improving health-care provider stroke-related dietary knowledge in Uganda and encouraging the use of potash as a salt substitute would help reduce hypertension and thereby lower the risk of stroke. [ABSTRACT FROM AUTHOR]

Roughly 25% of those with bipolar disorder (BD) are 60 years or older, and this proportion is likely to increase in tandem with changes in global demographics. Aging-related trajectories may also start in mid adulthood and lead to worse health outcomes such as cognitive decline and early mortality. The Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) project, a multi-national research initiative, pools archival research and clinical datasets to provide an evidence platform with potential to advance knowledge on older age BD (OABD). Key goals of investigators collaborating on the GAGE-BD project are to examine correlates of age of onset, understand BD mood symptom presentations, and set the stage for future investigations in aging-related changes in brain structure and functioning. In the first presentation, Dr. Lavin will describe an analysis of clinical correlates of late vs. early-onset BD. The majority of patients with BD have an onset before 40 years old. However, a significant number of individuals have onset of illness after age 40, commonly referred to as late-onset BD. This examination of a large international dataset sheds light on the association between the age of onset of BD symptoms and the distribution of risk factors and course of illness. Findings can yield important insights into the mechanisms involved in the evolution of BD across the life-span. In the second presentation, Dr. Blumberg will present on a new initiative to link neuroimaging findings with clinical data from the GAGE –BD sample. This talk will summarize procedures to harmonize aggregate data and how multi-national teams can collaborate to grow research capacity that is intended to better understand aging-related changes in brain structure and the relationship of the changes to demographic and clinical factors. Preliminary findings comparing older adults with BD to healthy participants on gray matter volume from structural magnetic resonance imaging (MRI) data, and white matter microstructure from diffusion-weighted MRI data, will be presented. In the third presentation, Dr. Eyler will discuss BD symptom severity mixity in OABD. The Diagnostic and Statistical Manual (DSM-5) includes a 'with mixed features' specifier that applies to a manic /hypomanic or to a depressive episode. Findings from the GAGE-BD samples suggested mixed features are relatively common in OABD, but do not suggest that mixity is associated with functional status. Future studies need to investigate whether mixed symptoms could contribute to BD neuroprogression in later life. Following the presentations, there will be discussion and ample opportunity for questions regarding emerging issues most relevant to OABD [ABSTRACT FROM AUTHOR]

Valbenazine is a selective and potent vesicular monoamine transporter 2 (VMAT2) inhibitor approved for the treatment of tardive dyskinesia (TD), a persistent and potentially disabling movement disorder associated with prolonged exposure to antipsychotics or other dopamine-receptor blocking agents (DRBAs). Valbenazine is the only approved TD medication with once-daily dosing and no requirements or cautions for dosing based on age. Older adults (≥55 years) have an increased risk for TD after a shorter duration of treatment with DRBAs, and previous analyses have shown that valbenazine is effective and well tolerated in this population (Sajatovic et al, Int J Geriatr Psychiatry 2020). The current presentation includes findings from the first analyses to evaluate the effects of an approved TD medication in an elderly population, using the more conventional age cutoff of ≥65 years. Data from two long-term studies (KINECT 3-extension, KINECT 4) of participants receiving up to 48 weeks of once-daily treatment with valbenazine (40 mg or 80 mg) were pooled and analyzed by age (≥65 and <65 years). Analyses included mean change from baseline (CFB) to Week 48 in Abnormal Involuntary Movement Scale (AIMS) total score. AIMS response at Week 48 was also assessed as follows: clinically meaningful response (≥30% improvement from baseline); protocol-defined response (≥50% improvement from baseline). Additional analyses included response thresholds for Clinical Global Improvement-Tardive Dyskinesia (CGI-TD) and Patient Global Impression of Change (PGIC) as follows: rating of "minimally improved" or better (score ≤3) at Week 48 (CGI-TD≤3, PGIC≤3); rating of "much improved" or "very much improved" (score ≤2) at Week 48 (CGI-TD≤2, PGIC≤2). Treatment-emergent adverse events (TEAEs) were also monitored. Treatment outcomes were generally robust and comparable between the age subgroups. Pooled AIMS results indicated substantial improvements in TD movements were found in both age subgroups with valbenazine 40 mg (≥65 years, n=8; <65 years, n=46) and 80 mg (≥65 years, n=20; <65 years, n=105): mean CFB (≥65 years, -6.4 and -9.8 [for 40 and 80 mg, respectively]; <65 years, -5.5 and -8.3); clinically meaningful ≥30% response (≥65 years, 75% and 95%; <65 years, 61% and 80%); and protocol-defined ≥50% response (≥65 years, 75% and 85%; <65 years, 50% and 70%). CGI-TD and PGIC response rates indicated that clinician- and patient-reported global improvements were also substantial in both age subgroups: CGI-TD≤3 (≥65 years, 88% and 100% [for 40 and 80 mg, respectively]; <65 years, 89% and 97%); CGI-TD≤2 (≥65 years, 88% and 95%; <65 years, 62% and 83%); PGIC≤3 (≥65 years, 88% and 100%; <65 years, 89% and 94%); PGIC≤2 (≥65 years, 75% and 90%; <65 years, 77% and 80%). Analyses of TEAEs indicated no statistically significant differences between age subgroups for the incidence of any TEAEs (≥65 years, 73%; <65 years, 72%) or any serious TEAEs (≥65 years, 18%; <65 years, 17%). However, discontinuations due to TEAEs were significantly more common in elderly participants (≥65 years, 26%; <65 years, 13%; P <0.05). These analyses, which are the first to evaluate any approved TD medication in patients ≥65 years, indicate that long-term treatment with once-daily valbenazine is appropriate and beneficial for this age group. Elderly study participants had clinically meaningful and substantial improvements in TD that were comparable to (or better than) those in the younger cohort. These results may provide clinicians with important information about the management of TD in elderly patients. Neurocrine Biosciences, Inc. [ABSTRACT FROM AUTHOR]

Background Internalized stigma, which occurs when stigmatized individuals accept society's assessment and incorporate this assessment into their sense of self, is prevalent in individuals with bipolar disorder (BD). This study explored the correlates of internalized stigma in a research sample of patients with BD who were poorly adherent to their medications. Methods Both quantitative and qualitative analyses were performed. Scores of 115 individuals with BD on the Internalized Stigma of Mental Illness (ISMI) scale were correlated with scores on the General Self-Efficacy (GSE) Scale, Brief Psychiatric Rating Scale (BPRS), Montgomery–Asberg Depression Rating Scale (MADRS), and Young Mania Rating Scale (YMRS). Regression was run for GSE (dependent variable) and ISMI (independent variable). In-depth qualitative interviews were conducted on a representative subsample (N = 21). Results Internalized stigma levels were moderately high. Internalized stigma and self-efficacy correlated, and internalized stigma related to self-efficacy after adjusting for demographic variables (age, gender, years of education), comorbidities, and symptom severity (BPRS and MADRS). Internalized stigma was also associated with the BD symptoms of depression, anxiety, guilt feelings, suspiciousness, and hallucinogenic behaviors. No association was found with mania. Conclusions Because internalized stigma has strong psychosocial and psychiatric symptom associations, it is recommended that clinicians address both societal stigma and internalized stigma. Strategies such as cognitive–behavioral therapy may help modify BD patients' internalized stigma. [ABSTRACT FROM AUTHOR]

Objective: To understand factors related to managing illness in older individuals with serious mental illness (SMI). Methods: Baseline data from 200 individuals with SMI and diabetes enrolled in a study were used to compare characteristics between older (age >55) vs. younger (age ≤55) individuals. Results: Older individuals had better diabetes control compared to younger individuals, those with major depressive disorder had diabetes for a longer duration, worse diabetic control, and more emergency department encounters. Conclusions: Helping younger individuals with SMI learn to manage their mental and physical health early-on might minimize the negative and cumulative effect of diabetes. [ABSTRACT FROM AUTHOR]

Objectives: Exercise can improve motor function in people with Parkinson's disease but depression reduces the motivation to participate in regular exercise. The aim of this study was to develop a novel Enhanced Exercise Therapy program that uses manual-driven guided exercise and peer-facilitated psychoeducation for individuals with Parkinson's disease and depression.Design: 24 week randomized controlled design.Methods: Thirty individuals were randomized to Enhanced Exercise Therapy or self-guided therapy, and evaluated at baseline, 12-weeks and at 24-weeks. Enhanced Exercise Therapy included group exercise and group psychoeducation for 12 weeks. Between 13 and 24 weeks, individuals had access to the fitness facility but group sessions were not held. Self-guided therapy included written guidelines for a self-paced exercise program and psychoeducation. Primary outcome measures included the number of exercise sessions and International Physical Activity Questionnaire score. Secondary measures included resting heart rate, supine blood pressure, estimated VO2max and incidence of orthostatic hypotension.Results: Twenty four individuals completed the study (80% retention) and both groups attended similar number of exercise sessions. There were no significant changes in cardiovascular fitness measures but there was a significant increase in the amount of physical activity in the Enhanced Exercise Therapy group and a decrease in the self-guided therapy group during the post-intervention period.Conclusions: Enhanced Exercise Therapy appears to promote engagement in an exercise program and more physical activity, even after group sessions were concluded in individuals with Parkinson's disease and depression. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the utility of Patient-Reported Outcomes Measure Information System Depression Scale (PROMIS-8a) compared with selected "Legacy" depression scales, including the Montgomery-Asberg Depression Rating Scale (MADRS), Geriatric Depression Scale (GDS), and GDS-Short Form (GDS-SF). Additionally, the measures' properties were assessed across levels of cognitive functioning.Methods: This cross-sectional analysis was extracted from a prospective cohort study. PROMIS-8a and Legacy depression measures were administered to individuals aged at least 70 years grouped by cognitive status based on the Saint Louis University Mental Status Examination. McNemar tests were run to determine if measures categorized the absence or presence of depression differently and item analysis evaluated classification discrepancies.Results: Sample mean age was 78, and most participants were women (71%), white (79%), with at least a high school education (89%). The percentage of individuals with at least mild depression was similar across measures (20.7% PROMIS-8a, 19.0% MADRS, 17.9% GDS, 13.9% GDS-SF). PROMIS-8a total score correlated moderately with MADRS (r = 0.56, df = 295, p <0.01), GDS (r = 0.68, df = 291, p <0.01), and GDS-SF (r = 0.60, df = 291, p <0.01), and predictive validity of the measures was similar. There were no significant mean differences on depression measures by cognitive status.Conclusion: Although all measures identified a similar percent of depressed individuals, the classification differed by measure. Item analysis showed that PROMIS-8a was more likely to identify feelings of dysphoria while the MADRS and GDS were more likely to identify physiologic aspects of depression. Given the brevity and ease of administration of the PROMIS-8a, it appears to be a useful depression screen for community-dwelling older adults. [ABSTRACT FROM AUTHOR]

Objectives: While medication treatment is necessary for the successful management of bipolar disorder (BD), non-adherence rates are up to 60%. Although medication attitudes are believed to be relevant to adherence behavior, few studies have investigated the trajectories of adherence change. This study evaluated attitudinal correlates of adherence conversion in 86 poorly adherent individuals with BD. Methods: This secondary analysis pooled data from two uncontrolled prospective trials of customized adherence enhancement (CAE), a psychosocial intervention delivered over 4-6 weeks. Poor adherence was defined as missing at least 20% of prescribed BD medication based on the self-reported Tablets Routine Questionnaire (TRQ). The sample was dichotomized into converters who achieved good adherence (N = 44) and non-converters who remained poorly adherent (N = 21). Converters vs. non-converters were compared on adherence, attitudes, and symptoms at baseline, 6 weeks and 3 months. Results: At baseline, converters and non-converters were similar demographically and clinically, but converters were less non-adherent (32% doses missed) than non-converters (59% missed). At 6 weeks, converters had better attitudes than non-converters. At 3 months, converters maintained improvements, but group differences were less pronounced due to some improvement in non-converters. Converters had better adherence at 3 months and trajectories differed for the groups on attitudes. Symptoms gradually improved for both converters and non-converters. Conclusions: Over two-thirds of poorly adherent BD patients who received CAE converted to good adherence. Improved medication attitudes may be a driver of improved adherence behavior and ultimately reduce BD symptoms. [ABSTRACT FROM AUTHOR]

The article presents a study analyzing psychiatric and medical co-morbidity in a Dutch bipolar elderly cohort by record review and structured clinical interviews, revealing a relative uncommon psychiatric co-morbidity and common medical co-morbidity and medication use. Topics discussed include an overview of bipolar disorder, the low prevalence of anxiety spectrum disorders, and the prevalence of substance abuse disorders.

Abstract: Background: It has been demonstrated that 46% to 48% of individuals with bipolar disorder (BD) are at least partially nonadherent with prescribed medication. Reports of whether male gender is a predictor of treatment nonadherence in BD have been inconsistent. The construct of gender may also be a matter of cultural orientation, and psychological gender, as a component of self-perception, may affect the experience of mental illness. Gender identity is the subjective experience of one''s individuality as male or female. Objective: This cross-sectional study evaluated gender and gender identity among men and women with BD as they relate to self-reported medication treatment adherence. Methods: This secondary analysis of a larger study on treatment adherence evaluated men and women with BD being treated with mood-stabilizing medications in a community mental health clinic. Gender identity and treatment adherence were evaluated using the Bem Sex Role Inventory (BSRI) and the Tablets Routine Questionnaire, respectively. Other measures included assessing BD symptoms using the Hamilton Depression Rating Scale and mania symptoms using the Young Mania Rating Scale, as well as psychosocial support with the Interpersonal Support Evaluation List and locus of control with the Multidimensional Health Locus of Control Scale. Results: Mean age of the 70 men and 70 women with type I BD was 43.1 years for adherent patients and 40.8 years for nonadherent patients. Women with BD had mean scores on the BSRI consistent with general population norms, whereas men with BD had scores suggesting lower levels of self-perceived masculinity than population norms. There were no differences between men and women on adherence; however, men with high BSRI masculinity scores had less adherence than other men in the sample (P = 0.04). Lower scores on the “powerful others” dimension of locus of control were associated with lower adherence. For women, there was no relationship between BSRI masculinity scores and adherence. Conclusions: Gender identity in men with BD differed from general population norms and appeared to be related to adherence. Treatment approaches that are intended to optimize adherence need to consider the construct of gender identity or gender role. ClinicalTrials.gov ID: NCT00183495. [Copyright &y& Elsevier]

Abstract: Aim: Nonadherent individuals are the most likely to avoid participating in research studies, thus limiting potential opportunities to develop evidence-based approaches for adherence enhancement. This mixed-method analysis evaluated factors related to adherence among 20 poorly adherent community mental health clinic patients with bipolar disorder (BD). Methods: Illness experience was evaluated with qualitative interview. Quantitative assessments measured symptoms (Hamilton Depression Rating Scale, Young Mania Rating Scale, Brief Psychiatric Rating Scale), adherence behavior, and treatment attitudes. Poor adherence was defined as missing 30% or more of medication. Results: Minorities (80%), unmarried individuals (95%), and those with substance abuse (65%) predominated in this nonadherent group of patients with BD. Individuals were substantially depressed (mean Hamilton Depression Rating Scale, 19.2), had at least some manic symptoms (mean Young Mania Rating Scale, 13.6), and had moderate psychopathology (mean Brief Psychiatric Rating Scale, 41.2). Rates of missed medications were 41% to 43%. Forgetting to take medications was the top reason for nonadherence (55%), followed by side effects (20%). Disorganized home environments (30%), concern regarding having to take long-term medications (25%) or fear of side effects (25%), and insufficient information regarding BD (35%) were relatively common. Almost one third of patients had individuals in their core social network who specifically advised against medication. Access problems included difficulty paying for medications among more than half of patients. Interestingly, patients reported good relationships with their providers. Conclusions: Forgetting to take medication and problems with side effects are primary drivers of nonadherence. Lack of medication routines, unsupportive social networks, insufficient illness knowledge, and treatment access problems may likewise affect overall adherence. Complementary quantitative and qualitative data collection can identify reasons for nonadherence and may inform specific clinical approaches to enhance adherence. [Copyright &y& Elsevier]

Abstract: Objective: Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research but also in clinical trials in which medications are being evaluated and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on “Methodological Challenges in Psychiatric Treatment Adherence Research” held on September 27–28, 2007, in Bethesda, MD, and organized by the National Institute of Mental Health (NIMH). Methods: This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed. Results: Each of the adherence measures described are imperfect estimates of actual medication ingestion, but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures. Conclusion: While adherence assessment has become increasingly sophisticated in recent years, there remains a need for refinement and expansion on currently available methods and measures. [ABSTRACT FROM AUTHOR]

Abstract: Background: Subjective experience of illness affects outcomes among populations with bipolar disorder (BD). This cross-sectional study combined qualitative and quantitative approaches to evaluate perceived treatment effects, concerns and expectations among 90 individuals with BD. Methods: Adults with Type I BD, mean age 36.6 years, 51% women, completed a semi-structured interview that was audio taped, transcribed, coded and analyzed along emergent themes. Quantitative scales measured depressive symptoms (Hamilton Depression Scale/HAM-D), psychopathology (Clinical Global Impression/CGI), and insight and treatment attitudes (Insight and Treatment Attitudes Questionnaire/ITAQ). Results: Individuals had moderate depression and psychopathology with good insight into need for treatment. Drug treatment was perceived as beneficial, by “stabilizing” or “balancing” mood (42%, N =38), decreasing anxiety/depressive symptoms (19%, N =17) and improving sleep (10%, N =9). While 39%, (N =35) of individuals denied medication concerns, nearly 29%, (N =26) feared possible long-term effects, particularly diabetes or liver/kidney damage. Media stories and advertisements contributed to medication fears. Hopes and expectations for treatment ranged from those that were symptom or functional status-based, such as desiring mood stabilization and elimination of specific symptoms (23%, N =21), to more global hopes such as “being normal” (20%, N =18) or “cured” (18%, N =16). Limitations: Limitations include relatively small sample, lack of a comparator, inclusion of only depressed individuals and those willing to discuss their illness experience. Conclusions: While individuals with BD appreciate the effects of medications, concerns regarding adverse effects and discrepancy between actual and hoped-for outcomes can be substantial. Subjective experience with medications using qualitative and quantitative methods should be explored in order to optimize treatment collaboration and outcomes. [Copyright &y& Elsevier]

Abstract: Background: Subjective experience of illness is a critical component of treatment adherence in populations with bipolar disorder (BPD). This cross-sectional analysis examined clinical and subjective variables in relation to adherence in 140 individuals with BPD receiving treatment with mood-stabilizing medication. Methods: Nonadherence was defined as missing 30% or more of medication on the Tablets Routine Questionnaire, a self-reported measure of medication treatment adherence. Adherent and nonadherent groups were compared on measures of attitudes toward illness and treatment including the Attitudes toward Mood Stabilizers Questionnaire, the Insight and Treatment Attitudes Questionnaire, the Rating of Medication Influences, and the Multidimensional Health Locus of Control Scale. Results: Except for substance abuse comorbidity, adherent individuals (n = 113, 80.7%) did not differ from nonadherent individuals (n = 27, 19.3%) on clinical variables. However, nonadherent individuals had reduced insight into illness, more negative attitudes toward medications, fewer reasons for adherence, and more perceived reasons for nonadherence compared with adherent individuals. The strongest attitudinal predictors for nonadherence were difficulties with medication routines (odds ratio = 2.2) and negative attitudes toward drugs in general (odds ratio = 2.3). Limitations: Results interpretation is limited by cross-sectional design, self-report methodology, and sample size. Conclusions: Comorbid substance abuse, negative attitudes toward mood-stabilizing medication, and difficulty managing to take medication in the context of one''s daily schedule are primary determinants of medication treatment adherence. A patient-centered collaborative model of care that addresses negative attitudes toward medication and difficulty coping with medication routines may be ideally suited to address individual adherence challenges. [Copyright &y& Elsevier]

Objectives: This study compares prescription patterns between young adults and elderly with bipolar disorder who achieved a recovery status during the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Design: STEP-BD is a multicenter National Institute of Mental Health-funded project designed to evaluate the longitudinal outcome of patients with bipolar disorder. The STEP-BD study involved extensive assessment across multiple domains including demographic data, diagnosis, symptom severity, treatment, and clinical status. Patients achieved "recovered" status when they experienced eight consecutive weeks without significant symptoms. Participants: The authors analyzed data of all subjects who achieved a recovered status at least once in their participation. Measurements: The authors compared treatment regimes and doses among young participants with middle age (N = 3,364), 20 -59 years old, and older participants 60 and above (N = 246). Results: Of the 3,615 STEP-BD participants who had a lifetime diagnosis of bipolar subtypes I or H, 67.6% (N = 2442) achieved a recovered status during their participation. A total of 78.5% (N = 193) of older patients recovered compared with 66.8% of the younger cohort. On average,participants who reached a recovered status took 2.05 medications with no difference between age groups Lithium was prescribed to 37.8% of younger patients compared with only 29.5% of older participants. The mean dosages taken by younger and older patients differed significantly only for lithium, valproate, and risperidone with elderly individuals prescribed lower daily dosages. Significant reduction in lithium dosing was observed among individuals aged 50 and older and among individuals 60 and older for valproate. Although valproate was more often prescribed, 42.1% of recovered bipolar elder achieved recovery with lithium alone compared with only 21.3% of the younger cohort. Conclusion: This data shows recovery is achievable in the elderly though more than one medication is often needed regardless of age. [ABSTRACT FROM AUTHOR]

Objective: Bipolar disorder is a chronic mental illness associated with substantial impairment in quality of life and function. Although there has been tremendous growth in understanding bipolar disorder with respect to treatments, very little study has focused on the viewpoint of affected individuals. The purpose of this study was to examine the subjective experience of illness among 19 men and women with rapid cycling bipolar disorder receiving treatment at an academic psychiatry clinic.Methods: Personal constructs of illness with respect to life-trajectory and societal reaction to the individual, specifically the issue of stigma, were evaluated using a semistructured, open-ended anthropological interview.Results: Participants perceived bipolar disorder as a disease with biologic underpinnings. Stigma was a major issue for all individuals. In common with individuals without serious mental illness, individuals with bipolar disorder work at mastering developmental tasks appropriate for their life stage. At times, younger individuals appeared to have difficulty separating their own identity from the effects of illness. For older individuals with bipolar disorder, life was perceived to be disrupted by bipolar disorder, with early plans and dreams often "derailed."Conclusion: Although bipolar disorder may severely alter an individual's planned life trajectory, accomplishment of life goals can at least partially offset the sense of loss that is often seen in bipolar illness. [ABSTRACT FROM AUTHOR]

Abstract: Background: Up to 48% of patients with bipolar disorder are either nonadherent or partially adherent to antipsychotic drug treatment. Medication adherence may differ by bipolar disorder subtype. Objective: This study evaluated the association between antipsychotic treatment adherence and mental health care use among individuals with bipolar disorder with predominantly manic/mixed symptoms or predominantly depressive symptoms. Methods: Individuals with bipolar or manic disorder who had at least 1 medical claim with International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.4-296.8 (bipolar disorder) or 296.0 or 296.1 (manic disorder) were identified from medical and pharmacy claims in the PharMetrics database for the period from January 1999 through December 2004. Adherence was measured by intensity (medication possession ratio [MPR]) and treatment duration. The association between adherence and health care use during and after antipsychotic treatment was evaluated using multiple regression analysis. The traditional P < 0.05 threshold was used for statistical significance; however, results that approached significance at P < 0.10 were also noted. Results: Claims data were examined for 13,941 antipsychotic treatment episodes occurring in 12,952 individuals with bipolar or manic disorder. Of these, 6153 treatment episodes occurred in 5711 individuals with predominantly manic/mixed symptoms, and 2617 occurred in 2381 individuals with predominantly depressive symptoms. The remaining 5171 treatment episodes occurred in 4860 individuals with unspecified bipolar disorder and were not included in the analysis. In individuals with manic/mixed symptoms, a higher MPR was associated with reduced total and outpatient mental health expenditures over subsequent stages of treatment (reduction in total expenditure per 1-point increment in MPR: $123-$439; P < 0.001). In individuals with predominantly depressive symptoms, the association between MPR and subsequent mental health expenditure reached statistical significance only in months 10-12, the 3rd of the 4 treatment segments examined (total mental health expenditure: -$714 [P < 0.001]; outpatient mental health expenditure: -$468 [P < 0.001]). A higher MPR was also associated with a lower likelihood of acute mental health care (inpatient hospitalization or an emergency department visit) in subsequent months in individuals with manic/mixed symptoms or depressive symptoms (odds ratio = 0.545 [95% CI, 0.30- 1.00] and 0.395 [95% CI, 0.14-1.12], respectively; both NS at the P < 0.05 threshold), and was not associated with mental health inpatient days. In both subgroups, a longer duration of treatment was associated with lower total and outpatient mental health expenditures during the 4 months after the termination of treatment (both, P < 0.01). Conclusions: In these individuals with bipolar or manic disorder, improved adherence to antipsychotic treatment was associated with lower subsequent total and outpatient mental health care expenditures. This association was less pronounced in individuals with predominantly depressive symptoms than in those with predominantly manic/mixed symptoms. [Copyright &y& Elsevier]

Tardive dyskinesia (TD) is a persistent and potentially disabling movement disorder associated with prolonged antipsychotic exposure. Compared to younger patients, older patients have a higher risk of TD and may develop symptoms earlier during antipsychotic treatment. Valbenazine, a novel and highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor, is approved to treat TD in adults of all ages, with no dose adjustment required for older patients. The long-term effects of valbenazine on TD were evaluated in KINECT 4 (NCT02405091), an open-label study in which participants received up to 48 weeks of once-daily treatment with valbenazine. Abnormal Involuntary Movement Scale (AIMS) data from this study were analyzed post hoc to evaluate treatment responses in older (≥55 to 85 years) and younger (18 to <55 years) patients. KINECT 4 included participants who met the following criteria: ages 18 to 85 years; DSM-IV diagnosis of schizophrenia, schizoaffective disorder, or mood disorder; neuroleptic-induced TD for ≥3 months prior to screening; stable psychiatric status (Brief Psychiatric Rating Scale score <50); no high risk of active suicidal ideation or behavior. Stable doses of concomitant medications to treat psychiatric and medical disorders were allowed. Valbenazine dosing was initiated at 40?mg, with escalation to 80?mg at Week 4 based on clinical assessment of TD and tolerability; a dose reduction to 40?mg was allowed per clinical need. AIMS responses, ranging from ≥10% to 100% improvement from baseline in AIMS total score (sum of items 1-7), were analyzed at Week 48 based on scoring by site investigators, with certain thresholds defined descriptively as follows: minimal response (≥10% total score improvement from baseline); clinically meaningful response (≥30% improvement); robust response (≥50% improvement [protocol-defined threshold for AIMS response]); and maximal response (80-100% improvement). To further evaluate clinically meaningful changes in TD symptoms, shift analyses were conducted for each AIMS item (representing 7 different body regions) as follows: improvement/shift from score ≥3 (moderate/severe) at baseline to score ≤2 (none/minimal/mild) at Week 48. Of 163 participants in the safety/efficacy population, 103 (63.2%) had an available AIMS assessment at Week 48. At Week 48, the percentages of patients who met the criteria for minimal response (≥10% AIMS total score improvement from baseline) or clinically meaningful (≥30% improvement) response were similar between the older and younger subgroups (≥55 years; <55 years): minimal (97.1% [68/70]; 97.0% [32/33]); clinically meaningful (95.7% [67/70]; 90.9% [30/33]). For higher thresholds of AIMS response, older patients seemed more likely to experience improvements, as indicated by results for robust response (88.6% [62/70]; 81.8% [27/33]) and maximal response (44.3% [31/70]; 27.3% [9/33], which included 10 total patients who had 100% improvement (11.4% [8/70]; 6.1% [2/33]). For shift analyses (defined as AIMS item score ≥3 at baseline and score ≤2 at Week 48), some results were limited by small sample sizes. However, 100% of both older and younger participants met the shift criteria for lips, upper extremities, and lower extremities. Results for the remaining AIMS items were as follows (≥55?years, <55 years): face (100% [29/29], 91.7% [11/12]); jaw (97.4% [37/38], 100% [13/13]); tongue (100% [44/44], 93.3% [14/15]);and trunk (100% [18/18], 62.5% [5/8]). After 48 weeks of treatment with once-daily valbenazine, >95% of all KINECT 4 participants (older and younger) had a minimal AIMS total score response (≥10% improvement), >90% had a clinically meaningful response (≥30% improvement), and >80% had a robust response (≥50% improvement). Older patients seemed more likely than younger patients to achieve a maximal response, including 100% improvement, although these results may be limited by smaller sample sizes. Shift analyses based on AIMS item scores were supportive of AIMS total score responses. Together, the results presented in this post hoc analysis suggest that valbenazine is an appropriate long-term treatment for both older and younger adults with TD. This research was funded by: This study was sponsored by Neurocrine Biosciences, Inc. [ABSTRACT FROM AUTHOR]

An emerging literature suggests that a collaborative care model, in which patients are active managers of their illness within a supportive social environment, is a beneficial approach for individuals with bipolar disorder. One aspect of treatment that is often suboptimal among individuals with bipolar disorder is treatment adherence. Establishing an ideal collaborative model may offer an opportunity to enhance treatment adherence among individuals with bipolar disorder. This paper presents results from a qualitative exploration of patients' attitudes towards the collaborative care model and how individuals with bipolar disorder perceive treatment adherence within the context of the collaborative care model. All participants were actively enrolled in outpatient treatment at a Community Mental Health Center and part of a larger study that evaluated the Life Goals Program, a manual-driven structured group psychotherapy for bipolar disorder that is based on the collaborative practice model. The Life Goals Program is designed to assist individuals to participate more effectively in the management of their bipolar illness and to improve their social and work-related problems. Individuals were queried regarding their opinions on the ingredients for an effective client-provider relationship. Quantitative data were collected on baseline treatment adherence as well. Individuals treated for bipolar disorder in a community mental health clinic identified 12 key elements that they felt were critical ingredients to a positive collaborative experience with their mental health care provider. The authors conceptualized these elements around 3 emerging themes: patient-centered qualities, provider-centered qualities, and interactional qualities. Individuals with bipolar disorder perceived the ideal collaborative model as one in which the individual has specific responsibilities such as coming to appointments and sharing information, whereas the provider likewise has specific responsibilities such as keeping abreast of current "state-of-the-art" prescribing practices and being a good listener. Treatment adherence was identified as a self-managed responsibility within the larger context of the collaborative model. Individuals with bipolar disorder in this study placed substantial emphasis on the interactional component within the patient-provider relationship, particularly with respect to times when the individual may be more symptomatic and more impaired. It is important that clinicians and care providers gather information related to patients' perceptions of the patient-provider relationship when designing or evaluating services aimed at enhancing treatment adherence. [ABSTRACT FROM AUTHOR]