Amber V. Keller

The U.S. Military Veterans aged 65 and older comprise an estimated 43% of the 22 million living Veterans in the United States. Veterans have high rates of physical, psychiatric, and social challenges, but it is not known whether Veteran status confers additional risk for cognitive or functional impairments in later life. Thus, this investigation specifically compared older Veterans with their non-Veteran peers in cognitive functioning and performance-based functional capacity. Participants (N = 110; 29 Veterans and 81 non-Veterans) were part of a larger longitudinal study on biopsychosocial functioning in independently living older adult residents of a Continuing Care Senior Housing Community. The University of California San Diego Institutional Review Board approved the study and all participants provided written informed consent. Participants provided demographic and mental health information and were administered a comprehensive neuropsychological battery. Functional capacity was assessed using the UCSD Performance-Based Skills Assessment-Brief (UPSA-B), which uses financial and communication role-plays to assess everyday functioning skills. Neuropsychological scores were appropriately normed prior to analysis. Multivariate Analyses of Variances with post hoc t-tests and an Analysis of Covariance were used to examine neuropsychological and functional capacity differences, respectively, between Veterans and non-Veterans. Veterans did not differ from non-Veterans in educational attainment (16.4 years versus 15.5 years, P = 0.110), but they were significantly older (mean age 86.9 years ± 5.7, versus 81.74 years ± 6.53; P < 0.001) and were more likely to be male (X² [1, N = 110] = 62.39, P < 0.001). Thus, though neuropsychological norms already accounted for demographic differences in our participants, age and sex were controlled in the Analysis of Covariance predicting UPSA-B score from Veteran status. Results suggested that, compared to non-Veterans, Veterans had significantly worse performance in the list learning portion of a test of verbal memory (Hopkins Verbal Learning Test-Revised, Total Recall; t = 2.56, P = 0.012, d = 0.56). Veterans and non-Veterans did not significantly differ in performance on the delayed recall portion of the verbal learning test and did not differ on a cognitive screening test (Montreal Cognitive Assessment) or on measures of premorbid intellectual functioning (Wide Range Achievement Test-4 Reading), language (Boston Naming Test, Verbal Fluency), visual memory (Brief Visuospatial Memory Test-Revised), attention/working memory (WAIS-IV Digit Span), processing speed (WAIS-IV Digit Symbol Coding), executive function (Delis-Kaplan Executive Function System Trails and Color-Word Test), or functional capacity (UPSA-B). Because our examination of multiple outcomes might have inflated Type I error, we performed a post hoc adjustment of P values using Benjamini-Hochberg procedures and the group difference in verbal learning remained significant. Despite largely similar function in most domains, Veterans performed significantly more poorly in verbal list learning than their non-Veteran peers. Additional attention should be given to the understanding, assessment, and possible treatment of learning and memory differences in older Veterans, as this may be an area in which Veteran status confers additional risk or vulnerability to decline. This is the first study to compare objective neuropsychological and functional performance between older (age 65+) US Veterans and non-Veterans.

Mild traumatic brain injury (mTBI), depression, and PTSD are highly prevalent in post-9/11 veterans. With the comorbidity of depression and PTSD in post-9/11 veterans with mTBI histories and their role in exacerbating cognitive and emotional dysfunction, interventions addressing cognitive and psychiatric functioning are critical. Compensatory Cognitive Training (CCT) is associated with improvements in prospective memory, attention, and executive functioning and has also yielded small-to-medium treatment effects on PTSD and depressive symptom severity. We sought to examine neuropsychological correlates of PTSD and depressive symptom improvement in veterans with a history of mTBI who received CCT. Thirty-seven post-9/11 veterans with mTBI histories and cognitive complaints received 10 weekly 120-minute CCT group sessions. Participants completed a baseline neuropsychological assessment, including tests of premorbid functioning, attention/working memory, processing speed, verbal learning/memory, and executive functioning, and completed psychiatric symptom measures (PTSD and depression) at baseline, post-treatment, and a 5-week follow-up. Paired samples t-tests were used to examine statistically significant changes in PTSD (total and symptom cluster scores) and depressive symptom scores over time. Pearson’s correlations were calculated between neuropsychological scores and PTSD and depressive symptom change scores at post-treatment and follow-up. Neuropsychological measures identified as significantly correlated with psychiatric symptom change scores were entered as independent variables in multivariable regression analyses to examine their association with symptom change at post-treatment and follow-up. Over 50% of CCT participants had clinically meaningful improvement in depressive symptoms (≥17.5% score reduction), and over 20% had clinically meaningful improvement in PTSD symptoms (≥10-point improvement) at post-treatment and follow-up. Examination of PTSD symptom cluster scores revealed a statistically significant improvement in avoidance/numbing at follow-up. Bivariate correlations indicated that worse baseline performance on Category Fluency was moderately associated with PTSD symptom improvement at post-treatment. Worse performance on both Category Fluency and Category Switching Accuracy was associated with improvement in depressive symptoms at post-treatment and follow-up. Worse performance on Trail-Making Number-Letter Switching was also associated with improvement in depressive symptoms at follow-up. Subsequent regression analyses revealed that worse processing speed and worse aspects of executive functioning at baseline were associated with depressive symptom improvement at post-treatment and follow-up. Worse baseline performances on tests of processing speed and aspects of executive functioning were significantly associated with improvements in PTSD and depressive symptoms during the trial. Our results suggest that cognitive training may bolster skills that are helpful for PTSD and depressive symptom reduction and that those with worse baseline functioning may benefit more from treatment because they have more room to improve.

Objective:Suicide risk among individuals with psychosis is elevated compared to the general population (e.g., higher rates of suicide attempts [SA] and completions, more severe lethality of means). Importantly, suicidal ideation (SI) seems to be more predictive of near-term and lifetime SAs in people with psychosis than in the general population. Yet, many randomized controlled trials in psychosis have excluded individuals with suicidality. Additionally, research suggests better cognitive and functional abilities are associated with greater suicide risk in psychotic disorders, which is dissimilar to the general population, but studies examining the link between cognition and suicidality are scarce. Because neuropsychological abilities can affect how individuals are able to attend to their environment, solve problems, and inhibit behaviors, further work is needed to consider how they may contribute to suicide risk in people with psychotic disorders. We sought to examine associations between neuropsychological performance and current SI and SA history in a large sample of individuals with psychosis.Participants and Methods:176 participants with diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features completed clinical interviews, a neuropsychological assessment (MATRICS Consensus Cognitive Battery subtests), and psychiatric symptom measures (Positive and Negative Syndrome Scale [PANSS]; Montgomery-Asberg Depression Rating Scale [MADRS]. First, participants were divided into groups based on their current endorsement of SI in the past month on the Colombia Suicide Severity Rating scale (C-SSRS): those with current SI (SI+; n=86) and without current SI (SI-; n=90). We also examined lifetime history of SA (n=114) vs. absence of lifetime SA (n=62). Separate t-tests, chi-square tests, and logistic regressions were used to examine associations between neuropsychological performance and the two dichotomous outcome variables (current SI; history of SA).Results:The SI groups did not differ on diagnosis, demographics (e.g., age, gender, race, ethnicity, years of education, premorbid functioning), or on positive and negative symptoms. The SI+ group reported more severe depressive symptoms (t(169)= -5.90, p<.001) and had significantly worse performance on working memory tests than the SI- group (t(173)=2.28, p=.024). Logistic regression revealed that working memory performance uniquely predicted current SI+ group membership above and beyond depressive symptoms (B= -.040; OR= .96; 95% CI [.93, .99]; p= .034). The SA groups did not significantly differ on demographic variables or on positive/negative symptoms, but those with a history of SA had more severe depressive symptoms (t(169)= -2.80, p=.006) and worse performance on tests of working memory (t(173)=2.16, p=.033) and processing speed (t(166)=2.28, p=.024) than did those without a history of SA. Logistic regression demonstrated that after controlling for depressive symptom severity, working memory and processing speed did not predict unique variance in SA history (p=.25).Conclusions:Worse working memory performance was associated with SI in the past month in individuals with psychotic disorders. Although our finding is consistent with literature in other psychiatric populations, it conflicts with existing psychosis literature. Thus, a more nuanced examination of how cognition relates to SI/SA in psychosis is warranted to identify and/or develop optimal interventions.