Victimization in Early Adolescence, Stress, and Depressive Symptoms Among Aging Sexual Minority Men: Findings from the Multicenter AIDS Cohort Study.

Purpose: We investigated the relation between adversities in early adolescence and risk of a depressive phenotype in adulthood, and whether stress in adulthood modified these associations. Methods: A total of 1138 men who have sex with men (MSM) participated in a Multicenter AIDS Cohort substudy in which they reported on adversities in early adolescence. Poisson regression estimated prevalence ratios (PRs) for associations between adversities and a depressive phenotype in adulthood. Stratified analyses examined the effects of stress in the last year on the depressive phenotype. Results: In adjusted models, men who were verbally insulted; threatened by physical violence; had an object thrown at them; or punched, kicked, or beaten were at higher risk of having a depressive phenotype in adulthood (for ≥1 time per month vs. never, PR = 1.50, 95% confidence interval [CI] = 1.15-1.96; PR = 1.84, 95% CI = 1.45-2.34; PR = 2.00, 95% CI = 1.51-2.66; or PR = 1.78, 95% CI = 1.35-2.34, respectively.) Being threatened with a weapon approached statistical significance (PR = 1.89, 95% CI = 0.96-3.72). Although higher stress was associated with depression overall, early adolescent victimization was only associated with depression among MSM not reporting high levels of stress in the last year (for ≥1 time per month vs. never, PR = 1.68, 95% CI = 1.09-2.59; PR = 2.11, 95% CI = 1.40-3.17; PR = 2.24, 95% CI = 1.24-4.03; PR = 1.98, 95% CI = 1.22-3.22, respectively). Conclusion: The attenuation of relationships between adversities and depression among men reporting high stress may suggest that adult stress overshadows long-term effects of early adolescent victimization on adult depression. Victimization in early adolescence may increase the risk of sustained depressive symptoms in mid- to later life, reinforcing the need for preventive strategies.

Sexual Orientation Differences in Complementary Health Approaches Among Young Adults in the United States.

PURPOSE: Lesbian, gay, and bisexual (LGB) young adults experience a wide range of health disparities, compared to heterosexuals. However, LGBs also experience many barriers to conventional health care, including social stigma, lack of LGB-specific knowledge among providers, and lower rates of health insurance coverage, which may limit utilization of conventional health services. Complementary health approaches (CHA) may represent an alternative to conventional care, but very little is currently known about CHA use in this population. We examined whether and how LGB young adults differed from heterosexual young adults in use of CHA. METHODS: Data were from Wave III of the National Longitudinal Study of Adolescent to Adult Health (2001-2002). Fifteen types of CHA were considered. Descriptive and bivariate statistics were computed using design-based F tests, and logistic regression was used. Analyses were weighted and gender stratified. RESULTS: Almost 46% of gay/bisexual men used CHA in the past 12 months versus 26% of heterosexual men (p ≤ .001) and 50% of lesbian/bisexual women versus 30% of heterosexual women (p ≤ .001). LGBs also differed significantly on demographics, access to conventional care, and health behaviors. Multivariate results showed higher odds of CHA among LGBs relative to heterosexuals (adjusted odds ratio = 2.37 for men; adjusted odds ratio = 1.98 for women; both p ≤ .001). CONCLUSIONS: This is the first study to systematically demonstrate sexual orientation differences in CHA in a nationally representative sample of young adults. Public health wellness initiatives for sexual minorities should include evidence-based CHA in addition to conventional health services.

Depressive Symptom Trajectories, Aging-Related Stress, and Sexual Minority Stress Among Midlife and Older Gay Men: Linking Past and Present.

We concatenate 28 years of historical depressive symptoms data from a longitudinal cohort study of U.S. gay men who are now midlife and older (n = 312), with newly collected survey data to analyze trajectories of depressive symptomatology over time and their impact on associations between current stress and depressive symptoms. Symptoms are high over time, on average, and follow multiple trajectories. Aging-related stress, persistent life-course sexual minority stress, and increasing sexual minority stress are positively associated with depressive symptoms, net of symptom trajectories. Men who had experienced elevated and increasing trajectories of depressive symptoms are less susceptible to the damaging effects of aging-related stress than those who experienced a decrease in symptoms over time. Intervention efforts aimed at assisting gay men as they age should take into account life-course depressive symptom histories to appropriately contextualize the health effects of current social stressors.

Internalized gay ageism, mattering, and depressive symptoms among midlife and older gay-identified men.

OBJECTIVE: In this paper we introduce the construct of "internalized gay ageism," or the sense that one feels denigrated or depreciated because of aging in the context of a gay male identity, which we identify as an unexplored aspect of sexual minority stress specific to midlife and older gay-identified men. METHODS: Using a social stress process framework, we examine the association between internalized gay ageism and depressive symptoms, and whether one's sense of mattering mediates or moderates this association, controlling for three decades of depressive symptom histories. The sample is 312 gay-identified men (average age = 60.7 years, range = 48-78, 61% HIV-negative) participating in the Multicenter AIDS Cohort Study (MACS) since 1984/85, one of the largest and longest running studies of the natural history of HIV/AIDS in the U.S., who provided contemporary (2012/13) reports of stress experiences. RESULTS: We find that internalized gay ageism can reliably be measured among these men, is positively associated with depressive symptoms net of an array of other factors that may also influence symptomatology (including depressive symptom histories), and mattering partially mediates but does not moderate its effect on depressive symptoms. CONCLUSION: Midlife and older gay men have traversed unparalleled historical changes across their adult lives and have paved the way for younger generations of sexual minorities to live in a time of less institutionalized discrimination. Still, they are at distinct risk for feeling socially invisible and devalued in their later years.

Minority Stress and Stress Proliferation Among Same-Sex and Other Marginalized Couples.

Drawing from 2 largely isolated approaches to the study of social stress-stress proliferation and minority stress-the authors theorize about stress and mental health among same-sex couples. With this integrated stress framework, they hypothesized that couple-level minority stressors may be experienced by individual partners and jointly by couples as a result of the stigmatized status of their same-sex relationship-a novel concept. They also consider dyadic minority stress processes, which result from the relational experience of individual-level minority stressors between partners. Because this framework includes stressors emanating from both status- (e.g., sexual minority) and role-based (e.g., partner) stress domains, it facilitates the study of stress proliferation linking minority stress (e.g., discrimination), more commonly experienced relational stress (e.g., conflict), and mental health. This framework can be applied to the study of stress and health among other marginalized couples, such as interracial/ethnic, interfaith, and age-discrepant couples.

Urban neighbourhood unemployment history and depressive symptoms over time among late middle age and older adults.

BACKGROUND: Little is known about how a neighbourhood's unemployment history may set the stage for depressive symptomatology. This study examines the effects of urban neighbourhood unemployment history on current depressive symptoms and subsequent symptom trajectories among residentially stable late middle age and older adults. Contingent effects between neighbourhood unemployment and individual-level employment status (ie, cross-level interactions) are also assessed. METHODS: Individual-level survey data are from four waves (2000, 2002, 2004 and 2006) of the original cohort of the nationally representative US Health and Retirement Study. Neighbourhoods are operationalised with US Census tracts for which historical average proportion unemployed between 1990 and 2000 and change in proportion unemployed between 1990 and 2000 are used to characterise the neighbourhood's unemployment history. Hierarchical linear regressions estimate three-level (time, individual and neighbourhood) growth models. RESULTS: Symptoms in 2000 are highest among those residing in neighbourhoods characterised by high historical average unemployment beginning in 1990 and increasing unemployment between 1990 and 2000, net of a wide range of socio-demographic controls including individual-level employment status. These neighbourhood unemployment effects are not contingent upon individual-level employment status in 2000. 6-year trajectories of depressive symptoms decrease over time on average but are not significantly influenced by the neighbourhood's unemployment history. CONCLUSIONS: Given the current US recession, future studies that do not consider historical employment conditions may underestimate the mental health impact of urban neighbourhood context. The findings suggest that exposure to neighbourhood unemployment earlier in life may be consequential to mental health later in life.

Same-sex legal marriage and psychological well-being: findings from the California Health Interview Survey.

OBJECTIVES: We examined whether same-sex marriage was associated with nonspecific psychological distress among self-identified lesbian, gay, and bisexual adults, and whether it had the potential to offset mental health disparities between lesbian, gay, and bisexual persons and heterosexuals. METHODS: Population-based data (weighted) were from the 2009 adult (aged 18-70 years) California Health Interview Survey. Within-group analysis of lesbian, gay, and bisexual persons included 1166 individuals (weighted proportion = 3.15%); within-group heterosexual analysis included 35 608 individuals (weighted proportion = 96.58%); and pooled analysis of lesbian, gay, and bisexual persons and heterosexuals included 36 774 individuals. RESULTS: Same-sex married lesbian, gay, and bisexual persons were significantly less distressed than lesbian, gay, and bisexual persons not in a legally recognized relationship; married heterosexuals were significantly less distressed than nonmarried heterosexuals. In adjusted pairwise comparisons, married heterosexuals had the lowest psychological distress, and lesbian, gay, and bisexual persons who were not in legalized relationships had the highest psychological distress (P < .001). Psychological distress was not significantly distinguishable among same-sex married lesbian, gay, and bisexual persons, lesbian, gay, and bisexual persons in registered domestic partnerships, and heterosexuals. CONCLUSIONS: Being in a legally recognized same-sex relationship, marriage in particular, appeared to diminish mental health differentials between heterosexuals and lesbian, gay, and bisexual persons. Researchers must continue to examine potential health benefits of same-sex marriage, which is at least in part a public health issue.

Stress and mental health among midlife and older gay-identified men.

OBJECTIVES: We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage. METHODS: We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n = 202; average age = 56.91 years; age range = 44-75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States. RESULTS: Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects. CONCLUSIONS: Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.

The urban neighborhood and cognitive functioning in late middle age.

This study examines the association of cognitive functioning with urban neighborhood socioeconomic disadvantage and racial/ethnic segregation for a U.S. national sample of persons in late middle age, a time in the life course when cognitive deficits begin to emerge. The key hypothesis is that effects of neighborhood on cognitive functioning are not uniform but are most pronounced among subgroups of the population defined by socioeconomic status and race/ethnicity. Data are from the third wave of the Health and Retirement Survey for the birth cohort of 1931 to 1941, which was 55 to 65 years of age in 1996 (analytic N = 4,525), and the 1990 U.S. Census. Neighborhood socioeconomic disadvantage has an especially large negative impact on cognitive functioning among persons who are themselves poor, an instance of compound disadvantage. These findings have policy implications supporting "upstream" interventions to enhance cognitive functioning, especially among those most adversely affected by neighborhood socioeconomic disadvantage.

Urban Neighborhoods and Depressive Symptoms in Late Middle Age.

This study examines associations between multiple urban neighborhood characteristics (socioeconomic disadvantage, affluence, and racial/ethnic composition) and depressive symptoms among late middle aged persons and compares findings to those previously obtained for persons age 70 years and older. Survey data are from the Health and Retirement Study (HRS), a U.S. national probability sample of noninstitutionalized persons aged 51 to 61 years in 1992. Neighborhoods are 1990 U.S. census tracts. Hierarchical linear regression is used to estimate multilevel models. Depressive symptoms vary significantly across urban neighborhoods among late middle age persons. Neighborhood socioeconomic disadvantage is significantly associated with depressive symptoms, net of both individual-level sociodemographic and health variables. However, this association is contingent upon individual-level wealth in that persons with low wealth in the most disadvantaged neighborhoods report the most depressive symptoms. Unlike findings for older adults for whom neighborhood effects appear to be entirely compositional in nature, neighborhood context matters to subgroups of late middle age adults.

Depressive symptoms, chronic diseases, and physical disabilities as predictors of cognitive functioning trajectories in older Americans.

OBJECTIVES: To determine the concurrent influence of depressive symptoms, medical conditions, and disabilities in activities of daily living (ADLs) on rates of decline in cognitive function of older Americans. DESIGN: Prospective cohort. SETTING: National population based. PARTICIPANTS: A national sample of 6,476 adults born before 1924. MEASUREMENTS: Differences in cognitive function trajectories were determined according to prevalence and incidence of depressive symptoms, chronic diseases, and ADL disabilities. Cognitive performance was tested five times between 1993 and 2002 using a multifaceted inventory examined as a global measure (range 0-35, standard deviation (SD) 6.0) and word recall (range 0-20, SD 3.8) analyzed separately. RESULTS: Baseline prevalence of depressive symptoms, stroke, and ADL limitations were independently and strongly associated with lower baseline cognition scores but did not predict future cognitive decline. Each incident depressive symptom was independently associated with a 0.06-point lower (95% confidence interval (CI)=0.02-0.10) recall score, incident stroke with a 0.59-point lower total score (95% CI=0.20-0.98), each new basic ADL limitation with a 0.07-point lower recall score (95% CI=0.01-0.14) and a 0.16-point lower total score (95% CI=0.07-0.25), and each incident instrumental ADL limitation with a 0.20-point lower recall score (95% CI=0.10-0.30) and a 0.52-point lower total score (95% CI=0.37-0.67). CONCLUSION: Prevalent and incident depressive symptoms, stroke, and ADL disabilities contribute independently to poorer cognitive functioning in older Americans but do not appear to influence rates of future cognitive decline. Prevention, early identification, and aggressive treatment of these conditions may ameliorate the burdens of cognitive impairment.

Comorbidity in head and neck cancer: a critical appraisal and recommendations for practice.

Comorbidity, the presence of additional illnesses unrelated to the tumor, has a significant impact on the prognosis of patients with head and neck cancer. In these patients, tobacco and alcohol abuse contributes greatly to comorbidity. Several instruments have been used to quantify comorbidity including Adult Comorbidity Evaluation 27 (ACE 27), Charlson Index (CI) and Cumulative Illness Rating Scale. The ACE 27 and CI are the most frequently used indices. Information on comorbidity at the time of diagnosis can be abstracted from patient records. Self-reporting is less reliable than record review. Functional status is not a reliable substitute for comorbidity evaluation as a prognostic measure. Severity as well as the presence of a condition is required for a good predictive instrument. Comorbidity increases mortality in patients with head and neck cancer, and this effect is greater in the early years following treatment. In addition to reducing overall survival, many studies have shown that comorbidity influences disease-specific survival negatively, most likely because patients with high comorbidity tend to have delay in diagnosis, often presenting with advanced stage tumors, and the comorbidity may also prompt less aggressive treatment. The impact of comorbidity on survival is greater in younger than in older patients, although it affects both. For specific tumor sites, comorbidity has been shown to negatively influence prognosis in oral, oropharyngeal, laryngeal and salivary gland tumors. Several studies have reported higher incidence and increased severity of treatment complications in patients with high comorbidity burden. Studies have demonstrated a negative impact of comorbidity on quality of life, and increased cost of treatment with higher degree of comorbidity. Our review of the literature suggests that routine collection of comorbidity data will be important in the analysis of survival, quality of life and functional outcomes after treatment as comorbidity has an impact on all of the above. These data should be integrated with tumor-specific staging systems in order to develop better instruments for prognostication, as well as comparing results of different treatment regimens and institutions.

Menopause-associated symptoms and cognitive performance: results from the study of women's health across the nation.

A long-standing, but unproven hypothesis is that menopause symptoms cause cognitive difficulties during the menopause transition. This 6-year longitudinal cohort study of 1,903 midlife US women (2000-2006) asked whether symptoms negatively affect cognitive performance during the menopause transition and whether they are responsible for the negative effect of perimenopause on cognitive processing speed. Major exposures were depressive, anxiety, sleep disturbance, and vasomotor symptoms and menopause transition stages. Outcomes were longitudinal performance in 3 domains: processing speed (Symbol Digit Modalities Test (SDMT)), verbal memory (East Boston Memory Test), and working memory (Digit Span Backward). Adjustment for demographics showed that women with concurrent depressive symptoms scored 1 point lower on the SDMT (P < 0.05). On the East Boston Memory Test, the rate of learning among women with anxiety symptoms tested previously was 0.09 smaller per occasion (P = 0.03), 53% of the mean learning rate. The SDMT learning rate was 1.00 point smaller during late perimenopause than during premenopause (P = 0.04); further adjustment for symptoms did not attenuate this negative effect. Depressive and anxiety symptoms had a small, negative effect on processing speed. The authors found that depressive, anxiety, sleep disturbance, and vasomotor symptoms did not account for the transient decrement in SDMT learning observed during late perimenopause.

Urban neighborhood context and mortality in late life.

OBJECTIVE: To examine the contextual effects of urban neighborhood characteristics on mortality among older adults. METHOD: Data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD). Death is assessed between the baseline assessment (1993) and the first follow-up interview (1995). Neighborhood data are from the 1990 Census. RESULTS: The log odds of dying between the two time points are higher in high proportion Hispanic neighborhoods, net of individual-level sociodemographic variables, but this effect is partly mediated by individual-level health. The log odds of dying are significantly (p < .05) lower in affluent neighborhoods, controlling for all individual-level variables and neighborhood proportion Hispanic. DISCUSSION: There are survival-related benefits of living in an affluent urban neighborhood, which we posit may be manifested through the diffusion of innovations in health care and health-promotion activities.

Trajectories of cognitive function in late life in the United States: demographic and socioeconomic predictors.

This study used mixed-effects modeling of data from a national sample of 6,476 US adults born before 1924, who were tested 5 times between 1993 and 2002 on word recall, serial 7's, and other mental status items to determine demographic and socioeconomic predictors of trajectories of cognitive function in older Americans. Mean decline with aging in total cognition score (range, 0-35; standard deviation, 6.00) was 4.1 (0.68 standard deviations) per decade (95% confidence interval: 3.8, 4.4) and in recall score (range, 0-20; standard deviation, 3.84) was 2.3 (0.60 standard deviations) per decade (95% confidence interval: 2.1, 2.5). Older cohorts (compared with younger cohorts), women (compared with men), widows/widowers, and those never married (both compared with married individuals) declined faster, and non-Hispanic blacks (compared with non-Hispanic whites) and those in the bottom income quintile (compared with the top quintile) declined slower. Race and income differences in rates of decline were not sufficient to offset larger differences in baseline cognition scores. Educational level was not associated with rate of decline in cognition scores. The authors concluded that ethnic and socioeconomic disparities in cognitive function in older Americans arise primarily from differences in peak cognitive performance achieved earlier in the life course and less from declines in later life.

Urban neighborhood context and change in depressive symptoms in late life.

OBJECTIVES: This study examines associations between urban neighborhood sociodemographic characteristics and change over time in late-life depressive symptoms. METHODS: Survey data are from three waves (1993, 1995, and 1998) of the Study of Assets and Health Dynamics Among the Oldest Old, a U.S. national probability sample of noninstitutionalized persons aged 70 years or older in 1993. Neighborhoods are 1990 U.S. Census tracts. Hierarchical linear regression is used to estimate multilevel models. RESULTS: The average change over time in depressive symptoms varies significantly across urban neighborhoods. Change in depressive symptoms is significantly associated with neighborhood-level socioeconomic disadvantage and ethnic composition in unadjusted models but not in models that control for individual-level characteristics. CONCLUSIONS: Findings indicate that apparent neighborhood-level effects on change in depressive symptoms over time among urban-dwelling older adults reflect, for the most part, differences in characteristics of the neighborhood residents.

A multilevel analysis of urban neighborhood socioeconomic disadvantage and health in late life.

The associations between neighborhood context and various indicators of health are receiving growing empirical attention, but much of this research is regionally circumscribed or assumes similar effects across the life course. This study utilizes a U.S. national sample to investigate the association between urban neighborhood socioeconomic disadvantage and health specifically among older adults. Data are from 3442 participants aged 70 years and older in the 1993 Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, and the 1990 U.S. Census. Our approach underscores the importance of multiple dimensions of health (self-reported physician-diagnosed cardiovascular disease [CVD], functional status, and self-rated health) as well as multiple dimensions of neighborhood disadvantage, which are conceptualized as environmental hazards that may lead to a physiologically consequential stress response. We find that individual-level factors attenuate the association between neighborhood disadvantage and both CVD and functional status, but not self-rated health. Net of covariates, high neighborhood socioeconomic disadvantage is significantly associated with reporting poor health. In late life, neighborhood socioeconomic disadvantage is more consequential to subjective appraisals of health than diagnosed CVD or functional limitations.

Urban neighborhoods and depressive symptoms among older adults.

OBJECTIVE: This study seeks to determine whether depressive symptoms among older persons systematically vary across urban neighborhoods such that experiencing more symptoms is associated with low socioeconomic status (SES), high concentrations of ethnic minorities, low residential stability and low proportion aged 65 years and older. METHODS: Survey data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD), a 1993 U.S. national probability sample of noninstitutionalized persons born in 1923 or earlier (i.e. people aged 70 or older). Neighborhood data are from the 1990 Census at the tract level. Hierarchical linear regression is used to estimate multilevel models. RESULT: The average number of depressive symptoms varies across Census tracts independent of individual-level characteristics. Symptoms are not significantly associated with neighborhood SES, ethnic composition, or age structure when individual-level characteristics are controlled statistically. However, net of individual-level characteristics, symptoms are positively associated with neighborhood residential stability, pointing to a complex meaning of residential stability for the older population. DISCUSSION: This study shows that apparent neighborhood-level socioeconomic effects on depressive symptoms among urban-dwelling older adults are largely if not entirely compositional in nature. Further, residential stability in the urban neighborhood may not be emotionally beneficial to its aged residents.