Treatment Mechanisms With Homeless Veterans.

OBJECTIVE: Emotion regulation and social processes that longitudinally predict depressive symptom change have not yet been investigated as mechanisms of change within a residential treatment context for homeless veterans with substance use issues. METHODS: A longitudinal data analysis of 186 homeless veterans enrolled in a six-month residential rehabilitation and addiction treatment program was conducted to investigate the role of six different emotion regulation variables as well the impact of two relationship quality constructs when measured at three time points across treatment. RESULTS: A large effect size reduction in depressive symptoms occurred during treatment (η2 = .233), and further analyses revealed that early treatment changes in a single subtype of emotion regulation, one's ability to tolerate distress while engaging in goal-directed behavior, was the only mechanism that preceded continued reductions in depressive symptoms later in treatment (ß = .13, p < .001). Social mechanisms of change were not strong predictors of depressive symptom reduction. CONCLUSIONS: Distress tolerance skills, psychoeducation on the habituation process, and focusing on goal achievement may be particularly beneficial when treating substance use issues in homeless veterans who are also experiencing depressive symptoms during residential treatment.

Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model.

PURPOSE: The development, implementation, and pilot testing of a discharge medication reconciliation service managed by pharmacists with offsite telepharmacy support are described. SUMMARY: Hospitals' efforts to prepare legible, complete, and accurate medication lists to patients prior to discharge continue to be complicated by staffing and time constraints and suboptimal information technology. To address these challenges, the pharmacy department at a 324-bed community hospital initiated a quality-improvement project to optimize patients' discharge medication lists while addressing problems that often resulted in confusing, incomplete, or inaccurate lists. A subcommittee of the hospital's pharmacy and therapeutics committee led the development of a revised medication reconciliation process designed to streamline and improve the accuracy and utility of discharge medication documents, with subsequent implementation of a new service model encompassing both onsite and remote pharmacists. The new process and service were evaluated on selected patient care units in a 19-month pilot project requiring collaboration by physicians, nurses, case managers, pharmacists, and an outpatient prescription drug database vendor. During the pilot testing period, 6402 comprehensive reconciled discharge medication lists were prepared; 634 documented discrepancies or medication errors were detected. The majority of identified problems were in three categories: unreconciled medication orders (31%), order clarification (25%), and duplicate orders (12%). The most problematic medications were the opioids, cardiovascular agents, and anticoagulants. CONCLUSION: A pharmacist-managed medication reconciliation service including onsite pharmacists and telepharmacy support was successful in improving the final discharge lists and documentation received by patients.

Opioid use patterns and association with pain severity and mental health functioning in chronic pain patients.

OBJECTIVE: The objective of this study was to explore the relationship between patterns of opioid use, pain severity, and pain-related mental health in chronic pain patients prescribed opioids. DESIGN: The study was designed as a one-time patient interview with structured pain and opioid use assessments. SETTING: The study was set in a tertiary care medical center in the United States Department of Veterans Affairs. PATIENTS. Study participants were primary care patients with a pain condition for greater than 6 months who received at least one prescription for an opioid in the prior 12 months. OUTCOME MEASURES: The Prescription Drug Use Questionnaire was used to assess patterns of opioid use. The Pain Outcomes Questionnaire was used to assess pain-related functioning. RESULTS: Symptomatic use of opioid medication (e.g., taking an opioid in response to increased pain) was more common than scheduled (i.e., taking an opioid at regular times) or strategic use of opioid medication (e.g., taking an opioid specifically to engage in activities). Symptomatic use of opioids was associated with poorer pain-related mental health, after controlling for pain duration and pain-related physical functioning. Use of opioids in a scheduled pattern was associated with better pain-related mental health. Patients rarely reported that they used opioids strategically to facilitate functional activities. CONCLUSIONS: The patterns in which patients use their opioid medications are associated with their psychological functioning. This is consistent with theory regarding the potential impact of reinforcing effects of opioid medication on functional outcomes. Interventions to encourage strategic or scheduled opioid use warrant investigation as methods to improve pain outcomes with opioids.

Perceptions of the cognitive compensation and interpersonal enjoyment functions of collaboration among middle-aged and older married couples.

Perceptions of cognitive compensation and interpersonal enjoyment of collaboration were examined in three hundred middle-aged and older couples who completed measures of perceptions of collaboration, cognitive ability, marital satisfaction, an errand task and judged their spouse's affiliation. Older adults (especially men) endorsed cognitive compensation and interpersonal enjoyment and reported using collaboration more frequently than middle-aged adults. Greater need for cognitive compensation was related to lower cognitive ability only for older wives. Greater marital satisfaction was associated with greater interpersonal enjoyment. These two functions related to reports of more frequent use of collaboration and perceptions of spousal affiliation in a collaborative task.

The fit between stress appraisal and dyadic coping in understanding perceived coping effectiveness for adolescents with type 1 diabetes.

This study examined whether perceived coping effectiveness (PCE) was associated with better diabetes management and was higher when adolescents' dyadic coping was matched to shared stress appraisals. There were 252 adolescents with Type 1 diabetes who completed stress and coping interviews where they appraised mothers' and fathers' involvement in stress ownership (mine, indirectly shared, directly shared with parent), in coping (uninvolved, supportive, collaborative, or controlling), and rated their effectiveness in coping. Adolescents completed assessments of depressive symptoms (Children's Depression Inventory), self-care behaviors (Self-Care Inventory), and efficacy of disease management (Diabetes Self-Efficacy). Glycosylated hemoglobin levels were obtained from medical records. Higher PCE was associated with fewer depressive symptoms, self-care behaviors, and efficacy across age and, more strongly for older adolescents' metabolic control. Appraisals of support or collaboration from parents were more frequent when stressors were appraised as shared. PCE was enhanced when dyadic coping with mothers (but not fathers) was consistent with stress appraisals (e.g., shared stressors together with collaborative coping). Stress and coping is embedded within a relational context and this context is useful in understanding the coping effectiveness of adolescents.

Conflict and collaboration in middle-aged and older couples: II. Cardiovascular reactivity during marital interaction.

Marital strain confers risk of cardiovascular disease (CVD), perhaps though cardiovascular reactivity (CVR) to stressful marital interactions. CVR to marital stressors may differ between middle-age and older adults, and types of marital interactions that evoke CVR may also differ across these age groups, as relationship contexts and stressors differ with age. The authors examined cardiovascular responses to a marital conflict discussion and collaborative problem solving in 300 middle-aged and older married couples. Marital conflict evoked greater increases in blood pressure, cardiac output, and cardiac sympathetic activation than did collaboration. Older couples displayed smaller heart rate responses to conflict than did middle-aged couples but larger blood pressure responses to collaboration-especially in older men. These effects were maintained during a posttask recovery period. Women did not display greater CVR than men on any measure or in either interaction context, though they did display greater parasympathetic withdrawal. CVR to marital conflict could contribute to the association of marital strain with CVD for middle-aged and older men and women, but other age-related marital contexts (e.g., collaboration among older couples) may also contribute to this mechanism.

Conflict and collaboration in middle-aged and older couples: I. Age differences in agency and communion during marital interaction.

Prior theory and research regarding age differences in marital interaction suggest that older couples display and experience more positivity and less negativity than middle-aged couples. However, studies of overt behavior in older couples are relatively rare and have emphasized disagreement, neglecting other important contexts for older couples such as collaboration during everyday problem solving. Further, the affiliation or communion dimension of social interaction (i.e., warmth vs. hostility) is commonly assessed but not the control or agency dimension (e.g., dominance vs. submissiveness). The present study examined affect, cognitive appraisals, and overt behavior during disagreement (i.e., discussing a current conflict) and collaboration (i.e., planning errands) in 300 middle-aged and older married couples. Older couples reported less negative affect during disagreement and rated spouses as warmer than did middle-aged couples. However, these effects were eliminated when older couples' greater marital satisfaction was controlled. For observed behavior, older couples displayed little evidence of greater positivity and reduced negativity-especially women. During collaboration, older couples displayed a unique blend of warmth and control, suggesting a greater focus on emotional and social concerns during problem solving.

Associations of self-reports versus spouse ratings of negative affectivity, dominance, and affiliation with coronary artery disease: where should we look and who should we ask when studying personality and health?

OBJECTIVE: Aspects of negative affect and social behavior studied as risk factors for coronary heart disease are usually examined separately and through self-reports. Using structural models of these personality domains, we tested associations of self-reports and spouse ratings of anxiety, depressive symptoms, anger, affiliation and dominance with coronary artery disease (CAD). DESIGN: In 154 healthy older couples, the authors tested cross-sectional associations with CAD of three facets of negative affectivity and two dimensions of the Interpersonal Circumplex, (IPC) using scales derived from the NEO-PI-R. MAIN OUTCOME MEASURES: CAD was quantified as Agatston scores from CT scans of coronary artery calcification (CAC). RESULTS: Self-reports were generally unrelated to CAC, whereas spouse ratings were consistently associated, largely independent of potential confounds. When considered simultaneously, anxiety and anger were related to CAC but depression was not. When considered together, both dominance and (low) affiliation were related to CAC. CONCLUSIONS: Structural models of negative affectivity and social behavior can facilitate integrative study of psychosocial risk factors. Further, self-report measures of these traits might under-estimate related CHD risk.

Task control and cognitive abilities of self and spouse in collaboration in middle-aged and older couples.

Collaborative problem solving may be used by older couples to optimize cognitive functioning, with some suggestion that older couples exhibit greater collaborative expertise. The study explored age differences in 2 aspects of collaborative expertise: spouses' knowledge of their own and their spouse's cognitive abilities and the ability to fit task control to these cognitive abilities. The participants were 300 middle-aged and older couples who completed a hypothetical errand task. The interactions were coded for control asserted by husbands and wives. Fluid intelligence was assessed, and spouses rated their own and their spouse's cognitive abilities. The results revealed no age differences in couple expertise, either in the ability to predict their own and their spouse's cognitive abilities or in the ability to fit task control to abilities. However, gender differences were found. Women fit task control to their own and their spouse's cognitive abilities; men only fit task control to their spouse's cognitive abilities. For women only, the fit between control and abilities was associated with better performance. The results indicate no age differences in couple expertise but point to gender as a factor in optimal collaboration.

Maternal parenting style and adjustment in adolescents with type I diabetes.

OBJECTIVE: To investigate the cross-sectional relationship between maternal parenting style and indicators of well-being among adolescents with diabetes. METHODS: Seventy-eight adolescents (ages 11.58-17.42 years, M = 14.21) with type 1 diabetes and their mothers separately reported perceptions of maternal parenting style. Adolescents reported their own depressed mood, self-efficacy for managing diabetes, and diabetes regimen adherence. RESULTS: Adolescents' perceptions of maternal psychological control were associated with greater depressed mood regardless of age and gender. Firm control was strongly associated with greater depressed mood and poorer self-efficacy among older adolescents, less strongly among younger adolescents. Adolescents' perceptions of maternal acceptance were associated with less depressed mood, particularly for girls and with better self-efficacy for diabetes management, particularly for older adolescents and girls. Maternal reports of acceptance were associated only with adherence. CONCLUSIONS: Maternal parenting style is associated with well-being in adolescents with diabetes, but this association is complex and moderated by age and gender.

Age-related differences in ambulatory blood pressure during daily stress: evidence for greater blood pressure reactivity with age.

Prior research on age and emotions has found that older adults may show better physiological regulation to stressful stimuli than do younger adults. However, the stress reactivity literature has shown that age is associated with higher cardiovascular reactivity to laboratory stress (J. R. Jennings et al., 1997). The authors investigated these conflicting findings further by examining daily ambulatory blood pressure in 428 middle-aged to older adults. Consistent with the age and reactivity literature, relatively old individuals showed significantly greater increases in ambulatory diastolic blood pressure compared with younger individuals when dealing with daily stressors. However, results also revealed that relatively old individuals reported less of an increase in negative affect during daily stress compared with their younger counterparts. The results of this study are consistent with the age-related increase in cardiovascular risk but highlight the complex links between stress and different facets of the aging process.