Screening for Anxiety Disorders in Adults: US Preventive Services Task Force Recommendation Statement

Pharmacological treatment of anxiety in older adults: a systematic review and meta-analysis

BACKGROUND

Anxiety and its disorders are common in later life. Given the known risks of psychopharmacological treatments in older adults, clinical decision making for anxiety management should be guided by the strongest available evidence. This study aimed to comprehensively synthesise evidence on the pharmacological treatment of anxiety in older adults.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Cochrane Central, Embase, PsycINFO, and CINAHL from database inception to April 23, 2024, for randomised controlled trials on pharmacological treatments for anxiety in older adults (aged 60 years or older, mean age 65 years or older, or subgroup analyses meeting these criteria). Primary outcomes included reduction in anxiety symptoms, or treatment response, or remission. Standardised mean differences (SMD) were calculated for continuous variables and absolute difference and risk ratio (RR) for dichotomous variables. The risk of bias was assessed using the Cochrane Risk of Bias tool, and the certainty of evidence rated using GRADE. People with lived experience were involved in conducting this research. This trial is registered with PROSPERO (CRD42023407837).

FINDINGS

We identified 19 eligible studies, including 2336 participants, 1592 (68·15%) of whom were women and 722 (30·91%) men, and sex was not reported for the other 22 (0·94%) participants. Only eight of 19 studies reported on race or ethnicity, and study participants were predominantly White (1309 [91·6%] of 1428), and no studies reported outcomes related to gender. Antidepressants were more effective than placebo or waitlist control in reducing anxiety symptoms (SMD -1·19 [95% CI -1·80 to -0·58), with moderate certainty of evidence and substantial heterogeneity (I2 92·34%; p<0·0001). Antidepressants were also more effective than placebo or waitlist control in response or remission (RR 1·52 [95% CI 1·21 to 1·90]; absolute difference 146 per 1000 [95% CI 59 to 252]); with a low certainty of evidence and low heterogeneity (I2 8·09%; p=0·36). Planned subgroup analysis indicated selective serotonin reuptake inhibitors led to a greater reduction in anxiety symptoms (SMD -1·84 [95% CI -2·52 to -1·17]) compared with serotonin-norepinephrine reuptake inhibitors (SMD -0·46 [95% CI -0·65 to -0·27]), and there was no difference in response or remission. Benzodiazepines might reduce anxiety symptoms compared with placebo, but the evidence is very uncertain with high risk of bias. Meta-analyses for other drug classes for primary outcomes were not possible.

INTERPRETATION

Antidepressants are more effective than placebo or waitlist for reducing anxiety symptoms, with evidence supporting their safety and tolerability in older adults. Evidence for the efficacy and safety of benzodiazepines is weak. These findings can guide evidence-based practice.

FUNDING

Public Health Agency of Canada.

Associated factors to Generalized Anxiety in a sample of women screened for the risk of perinatal depression: a naturalistic study from Italy

BACKGROUND

The perinatal period is critical for women's physical and mental health. Anxiety and depressive symptoms are common, impacting both mothers and peripartum outcomes.

METHODS

This multicenter study in Southern Italy assessed 969 women attending three gynecological departments from January to November 2022. Evaluations occurred in the third trimester (T0) and at 7 days, 1 month, and 6 months postpartum (T1, T2, T3). The Generalized Anxiety Disorder-7 (GAD-7) and Edinburgh Postnatal Depression Scale (EPDS) screened for perinatal anxiety and depression. Additional measures assessed neuroticism, coping, attachment, resilience, and quality of life. A structured clinical interview confirmed anxiety diagnoses.

FINDINGS

At baseline, 8.97 % had generalized anxiety and 14.9 % screened positive for depression. Anxiety and depression were interrelated across time points. Generalized anxiety was linked to prior mental health issues, stressful life events, and premenstrual syndrome. Higher anxiety severity correlated with lower resilience, poorer quality of life, and maladaptive coping. Depressive symptoms persisted postpartum. Logistic regression identified key predictors of Generalized Anxiety Disorder, including higher EPDS scores, neuroticism, lower quality of life, avoidance, denial coping, emotional support needs, and premenstrual syndrome.

CONCLUSION

Routine screening, early intervention, and resilience-building are essential for individuals with high neuroticism, insecure attachment, or vulnerable coping strategies.

Anxiety and Related Disorders During the Perinatal Period

Anxiety and anxiety-related disorders are, as a group, the most common mental health conditions and are more common among women compared with among men. It is now evident that these disorders affect one in five pregnant and postpartum people and are more common than depression. For some disorders (e.g., obsessive-compulsive disorder), there is also evidence of an elevated risk for their development and exacerbation during perinatal periods. In this article, we review the literature pertaining to anxiety and anxiety-related disorders during the perinatal period. We also provide information related to pregnancy-specific anxiety and fear of childbirth constructs that exist outside of diagnostic classification but are particularly important in the perinatal context. We review the scope, prevalence, and etiology of these disorders as well as comorbidity, screening, assessment, and treatment. We conclude with an overview of some of the key gaps in knowledge and recommendations for future research.

Depression and anxiety in patients with atopic dermatitis: Recognizing and addressing mental health burden

The psychosocial burden of atopic dermatitis (AD) is extensive, stemming from intense itch, sleep disturbance, unpredictable flares, lifestyle restrictions and missed activities, social stigma, and treatment burden. Overall, adults with AD are at a 2- to 3-fold greater risk for depression and anxiety compared with individuals without AD and children at a 1.5-fold greater risk, with greatest risk for those with more severe disease. A number of mechanisms seem to affect the relationship between AD and mental health, including poorly controlled disease, sleep disturbance, stress-induced itch, inflammation, and coping patterns. In some cases, the mental health burden of AD may also negatively affect AD management and course, creating a reinforcing cycle of psychosocial burden. Although depression and anxiety are known comorbidities of AD, the mental health burden of AD often goes unaddressed, which may further a sense of isolation for patients and families. Given the strong association between symptom severity and increased mental health burden, optimizing AD treatment and reducing itch are critical. Health care professionals can support patients with AD and their caregivers by encouraging open conversations about mental health, addressing common areas of condition-related stress, screening for depression and anxiety, and facilitating referrals to mental health professionals for further assessment and evidence-based care. Existing research supports use of cognitive-behavioral interventions to help manage the physical and mental health burden of AD. Further research is needed to evaluate psychological interventions for pediatric patients with AD and for patients with clinical diagnoses of depression and anxiety to better guide shared decision-making around support for these patients.

Association of the "life's crucial 9" cardiovascular health with all-cause and cardiovascular disease mortality: a national cohort study

BACKGROUND

In 2022, the American Heart Association launched an updated algorithm for quantifying cardiovascular health (CVH), termed Life's Essential 8 (LE8). This new approach has been shown to be associated with various noncommunicable chronic diseases and mortality. However, LE8 did not take into consideration the importance of psychological health on CVH. Recently, a perspective article proposed Life's Crucial 9 (LC9), which would add psychological health as another component to LE8, as a novel metric to assess CVH. This study aims to investigate the association of LC9 with all-cause and cardiovascular disease (CVD) mortality.

METHODS

This study included 23,080 adults from National Health and Nutrition Examination Survey 2005-2018, and mortality was ascertained by linkage to National Death Index records through 31 December 2019. The LC9 scoring algorithm was categorized into low (0-49), moderate (50-79), and high (80-100) CVH. Weighted Cox proportional hazards regression models and restricted cubic spline analysis were applied to evaluate the association of LC9 with mortality.

RESULTS

During a median follow-up of 7.8 years, a total of 2,388 overall deaths were identified, covering 613 CVD deaths. Compared with adults with a low CVH score, those with a high CVH score had 52% (hazard ratio, 0.48; 95% confidence interval, 0.38-0.60) and 64% (0.36; 0.23-0.56) reduced risk of all-cause and CVD mortality. Similarly, a moderate CVH score was associated with 33% (0.67; 0.58-0.78) and 49% (0.51; 0.40-0.64) reduced risk of all-cause and CVD mortality. The population-attributable fractions of high vs. moderate or low CVH score were 46.0% for all-cause mortality and 75.8% for CVD mortality. Elevated blood lipids, high body mass index, and poor sleep quality were the three major contributors to all-cause mortality, whereas nicotine exposure, unhealthy psychology, and elevated blood lipids were the three significant ones to CVD mortality. There were approximately negative linear dose-response relationships of total LC9 score with all-cause and CVD mortality.

CONCLUSIONS

Adhering to a high LC9 score is related to a reduced risk of all-cause and CVD mortality. This new CVH definition shows promise as a primordial preventive strategy to reduce mortality rates.

Whose assets? Individual and household income and savings and mental health in a longitudinal cohort

While there is a growing understanding of the link between financial assets and mental health, the literature is lacking in two dimensions. First, although wealth (including savings) may better inform ability to cope with life's stressors than income alone, the role of wealth in shaping health is substantially understudied relative to income. Second, most studies measure income at the household level instead of the individual level. Using five waves of the nationally representative CLIMB survey collected in Spring 2020, 2021, 2022, 2023, and 2024, we estimated the odds of probable depression (Patient Health Questionnaire, PHQ-9≥10) and anxiety (GAD-7≥10) across individual and household level income and savings using generalized estimating equations to account for clustering over time at the individual level and to account for baseline mental health. Our sample included 1,314 participants across the five waves of the CLIMB survey. The average age of participants was 46.5 years [sd: 16.4] in 2020. When controlling for demographic variables, each financial asset was independently associated with mental health. In fully adjusted models where savings and income at the individual and household level were included, for every $10,000 more that an adult reported in individual annual income, they had 0.95 times the odds of probable depression (95%CI: 0.92, 0.99) and 0.95 time the odds of probable anxiety (95%CI: 0.91, 0.99), translating to 5% lower odds. Having $10,000 more in individual savings was associated with 0.95 times the odds of probable anxiety (95%CI: 0.91, 0.99). These findings suggest that 1) financial assets were each independently associated with mental health, 2) having higher individual income was associated with mental health even when adjusting for financial assets at the household and individual level, and 3) higher individual savings were associated with lower probable anxiety. Individual-level financial assets may be associated with mental health differently than household-level financial assets.

Generalized anxiety disorder in low-resourced adults: a nationally representative, longitudinal cohort study across the COVID-19 pandemic

The burden of generalized anxiety disorder (GAD) accrued disproportionately over the COVID-19 pandemic to low-resource populations. Using a longitudinal, nationally representative study of US adults, we used generalized estimating equations to estimate the burden of positive screen for GAD (GAD-7 score ≥ 10) over time. The final sample included 1270 adults at least 18 years old who completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being (CLIMB) Study, with data collected in spring 2020, 2021, and 2022. The national prevalence of positive screen for GAD decreased from 24.4% in 2020 to 21.3% in 2022 (P < .05). Across the COVID-19 pandemic, factors associated with increased odds of positive screen for GAD were lower income (odds ratio (OR) = 2.06 [95% CI, 1.17-3.63] for ≤$19 999 relative to ≥$75 000), younger age (OR = 2.55 [95% CI, 1.67-3.89] for ages 18-39 years relative to ≥60 years), and having contracted COVID-19 (OR = 1.54 [95% CI, 1.12-2.14]). Experiencing stressors was associated with 14% increased odds of positive screen for GAD for each additional stressor. The 2020 stressors most strongly associated with positive screen for GAD in 2022 were job loss and difficulty paying rent. Efforts to address the stressors affecting groups with the highest burden of anxiety after the pandemic may help mitigate poor mental health exacerbated during the COVID-19 pandemic.

Evidence-Based Periodic Health Examinations for Adults: A Practical Guide

Periodic health examinations, or annual clinical checkups, are a primary reason for seeking medical care. The objective is to identify hidden problems or diseases in their early stages and to promote behaviors that prevent or minimize the consequences of these conditions. However, the practice of conducting annual reviews with clinical, laboratory, and imaging examinations indiscriminately is not associated with outcomes that matter to the patient (such as reducing morbidity and mortality) and may result in harm, including overdiagnosis and overtreatment. The objective of the present work is to review and summarize the measures currently recommended and supported by scientific evidence from the main regulatory authorities of the United States (United States Preventive Services Task Force (USPSTF)) and Canada (Canadian Task Force on Preventive Health Care (CTFPHC)), in order to create a practical guide for evidence-based checkups.

Clinical outcomes from blended care therapy for anxiety and depression in the year after treatment

Background

Scalable evidence-based treatments for anxiety and depression, such as blended care therapy (BCT) that integrate digital tools are effective, but reporting on long-term outcomes is limited.

Method

This pragmatic observational study examined the symptom stability and trajectories of individuals in the year following engagement in a BCT program. Participants included adults with clinical anxiety and/or depression measured by the Generalized Anxiety Disorder-7 (GAD-7) or Patient Health Questionnaire-9 (PHQ-9). Assessments were sent during the initial episode of care and in the year following.

Results

Participants included 27,835 adults (depression: 17,686 and anxiety: 24,853). Of these, 11,465 (41 % of those who received initial care; depression: 7223; anxiety: 10,218) completed at least one follow-up assessment (FUA). Average age was 34 years, 68-69 % were female, and 48-49 % were White across subsamples. Among FUA respondents, rates of reliable improvement or recovery on the PHQ-9 or GAD-7 for those who did not receive additional therapy were above 81 % across follow-up periods. Growth curve analysis for those who did not return for additional therapy revealed that both depression and anxiety groups demonstrated a statistically significant yet small linear effect of time in the year following treatment, with a 1.6-2.1 point increase in scores over the 12-month period.

Conclusions

Among clients who completed FUAs and received no additional therapy, reliable improvement and recovery rates were high. Growth curve analysis demonstrated a small increase in symptoms over the 12-month interval, providing pragmatic evidence of long-term stability of treatment gains from BCT for anxiety and depression in a real-world setting.

Mental Health Changes in US Transgender Adults Beginning Hormone Therapy Via Telehealth: Longitudinal Cohort Study

BACKGROUND

Gender-affirming hormone therapy (GAHT) has shown potential for improving mental health outcomes among transgender and gender-diverse adults. How clinical outcomes change among adults receiving GAHT via telehealth across the United States is not well known.

OBJECTIVE

This study evaluated the relationship between initiating GAHT via a telehealth clinic and changes in depression, anxiety, and suicide ideation over a 3-month period.

METHODS

This cohort study evaluated the relationship between initiating GAHT via a telehealth clinic and changes in mental health over a 3-month period. Data were collected at baseline and 3 months later among adults who had their first GAHT visit between August and November 2023. The study included adults aged 18 years and older initiating GAHT for the first time, with a final sample of 342 adults across 43 states (192 initiated estrogen and 150 initiated testosterone therapy). The primary outcomes were depression symptoms using the Patient Health Questionnaire-9 (PHQ-9), anxiety symptoms using the General Anxiety Disorder-7 (GAD-7), and suicide ideation in the past 2 weeks.

RESULTS

Before GAHT initiation, 40% (136/342) of participants reported depression (PHQ-9 ≥10), 36% (120/342) reported anxiety (GAD-7 ≥8), and 25% (91/342) reported suicidal ideation. By follow-up, significant reductions were observed in PHQ-9 (-2.4, 95% CI -3.0 to -1.8) and GAD-7 scores (-1.5, 95% CI -2.0 to -1.0). Among those with elevated symptoms, 40% (48/120) to 42% (56/133) achieved a clinically meaningful response (≥50% reduction in baseline scores), and 27% (36/133) to 28% (33/120) achieved remission (PHQ-9 or GAD-7 score <5). Of those with suicide ideation at baseline, 60% (50/83) had none at follow-up.

CONCLUSIONS

This study highlights the important relationship between telehealth-delivered GAHT and mental health, emphasizing the importance of accessible and timely care.

Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

BackgroundThe Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes clinical practice guidelines for mood and anxiety disorders. This CANMAT guideline aims to provide comprehensive clinical guidance for the pregnancy and postpartum (perinatal) management of mood, anxiety and related disorders.MethodsCANMAT convened a core editorial group of interdisciplinary academic clinicians and persons with lived experience (PWLE), and 3 advisory panels of PWLE and perinatal health and perinatal mental health clinicians. We searched for systematic reviews of prevention and treatment interventions for perinatal depressive, bipolar, anxiety, obsessive-compulsive and post-traumatic stress disorders (January 2013-October 2023). We prioritized evidence from reviews of randomized controlled trials (RCTs), except for the perinatal safety of medications where reviews of large high-quality observational studies were prioritized due to the absence of RCT data. Targeted searches for individual studies were conducted when systematic reviews were limited or absent. Recommendations were organized by lines of treatment based on CANMAT-defined levels of evidence quality, supplemented by editorial group consensus to balance efficacy, safety, tolerability and feasibility considerations.ResultsThe guideline covers 10 clinical sections in a question-and-answer format that maps onto the patient care journey: case identification; organization and delivery of care; non-pharmacological (lifestyle, psychosocial, psychological), pharmacological, neuromodulation and complementary and alternative medicine interventions; high-risk clinical situations; and mental health of the father or co-parent. Equity, diversity and inclusion considerations are provided.ConclusionsThis guideline's detailed evidence-based recommendations provide clinicians with key information to promote the delivery of effective and safe perinatal mental healthcare. It is hoped that the guideline will serve as a valuable tool for clinicians in Canada and around the world to help optimize clinical outcomes in the area of perinatal mental health.

Addressing perinatal mood and anxiety disorders in obstetric settings: results of a cluster randomized controlled trial of two approaches

BACKGROUND

Mood and anxiety disorders affect one in 5 perinatal individuals and are undertreated. While professional organizations and policy makers recommend that obstetric practices screen for, assess and treat mood and anxiety disorders, multi-level barriers to doing so exist. To help obstetric practices implement the recommended standard of care, we developed implementation assistance, an approach to guide practices on how to integrate screening, assessment, and treatment of mood and anxiety disorders into the obstetric practice workflow. To teach obstetric care clinicians how to treat perinatal mood and anxiety disorders, we also developed an e-learning course and toolkit.

OBJECTIVE

Evaluate the extent to which 1) implementation assistance + e-learning/toolkit, and 2) e-learning/toolkit alone improved the rates and quality of care for perinatal mood and anxiety disorders in obstetric practices, as compared to usual care.

STUDY DESIGN

We conducted a cluster randomized controlled trial involving 13 obstetric practices across the United States (US). Using 2:2:1 randomization, 13 obstetric practices were assigned to 1) implementation assistance + e-learning/toolkit (n=5), 2) e-learning/toolkit alone (n=5), or 3) usual care (n=3). We measured obstetric care clinicians' quality of care for perinatal mood and anxiety disorders (as measured by medical record documentation of screening, assessment, treatment initiation, and monitoring) documented in patient charts (n=1040). Effectiveness was assessed using multilevel generalized linear mixed models, accounting for clustering of repeated measurements (n=2, i.e., pre and post) within obstetric care clinicians' patient charts (n=40) nested within practices (n=13). Intention-to-treat and per-protocol analyses were conducted.

RESULTS

At baseline, no significant differences were observed among the 3 groups regarding documented mental health screening. Chart abstraction at 8 months post-training revealed a significant increase in recommended bipolar disorder screening only among the practices that received the implementation plus e-learning/toolkit (from 0.0% to 30.0%; p=.017). Practices receiving the e-learning/toolkit alone or usual care continued to not screen for bipolar disorder. Documented screening for anxiety also increased in the implementation + e-learning/toolkit group (from 0.5% to 40.2%), however, it did not reach statistical significance when compared to the other groups (P=.09). A significant increase in documented post-traumatic stress disorder (PTSD) screening was observed among practices receiving the implementation plus e-learning/toolkit (0.0% to 30.0%; P=.018). The quality-of-care score in the implementation + e-learning toolkit group increased from 20.5 at baseline to 42.8 at follow-up and was significantly different from both the e-learning/toolkit alone group (P=.02) and the usual care group (P=.03). At 8 months post-training, the implementation + e-learning/toolkit group had higher mean provider readiness scores than the other 2 groups for documentation of screening, assessment, and monitoring. However, documentation of treatment was the only component that reached statistical significance (P=.025).

CONCLUSION

Among the practices that followed the implementation protocols, implementation assistance + e-learning/toolkit was effective in improving rates of screening for bipolar disorder, anxiety, and PTSD. However, 3 of the 5 practices did not follow the implementation protocols, suggesting that the intensity of the implementation needs to be tailored based on practice readiness for implementation.

Internalizing Psychiatric Symptoms in People With Mosaicism for Trisomy 21

People with mosaicism for trisomy 21 have been shown to exhibit many of the same phenotypic traits present in people with non-mosaic Down syndrome, but with varying symptom severity. However, the behavioral phenotype of people with mosaic Down syndrome (mDS) has not been well characterized. This study aimed to examine the prevalence of self-report and caregiver-report symptoms of depression and anxiety among a sample of 62 participants with mDS aged 12-46 and assess their association with the percentage of trisomy 21 in blood and/or buccal mucosa cells. The overall MANCOVA revealed a significant effect of trisomy on the set of internalizing scales, controlling for age and gender (p = 0.038, partial eta2 = 0.22). However, follow-up univariate analyses showed that the initial significant effect of trisomy on fear (p = 0.049, partial eta2 = 0.08) did not survive correction for multiple comparisons (adjusted p = 0.300). No other effects were significant. This study highlights the high occurrence of depression and anxiety symptoms in individuals with mDS and the need for routine assessment to optimize their care. It also demonstrates the ability of people with mDS to complete these evaluations, thereby supporting their inclusion in research studies/clinical trials.

Use of telehealth by US adults with depression or anxiety disorder: Results from 2022 Health Information National Trends Survey

Background

Telehealth use has significantly increased recently. However, little is known about its use by individuals with depression or anxiety disorders. This study aims to explore the patterns of telehealth use among those individuals.

Methods

Data used were from the 2022 Health Information National Trends Survey (HINTS) cycle 6. Weighted logistic regression was performed to test the association between depression/anxiety disorder and telehealth use, and to explore reasons for using/not using telehealth among those with depression/anxiety, compared to those without.

Results

Out of the 4952 study participants, 2887 (weighted percentage: 39.36%) had used telehealth in the past 12 months. Those with depression/anxiety disorder had significantly higher telehealth use, compared to those without (57% vs. 32%; OR = 2.65; 95% CI: (2.04, 3.43)). Factors affecting telehealth use could differ by depression/anxiety disorder status. Among those with depression/anxiety disorder, being woman or married was not associated with telehealth use, whereas they were significant factors among those without depression/anxiety disorder. Among those with depression/anxiety, non-Hispanic Black participants (OR = 0.51; CI: (0.78, 0.94)) were less likely to use telehealth, compared to non-Hispanic White participants; additionally, higher income was associated with telehealth use. Regarding reasons for using telehealth, convenience (OR = 1.80; CI: (1.21, 2.68)) and avoiding COVID infection (OR = 1.40; CI: (1.06, 1.86)) were more likely considered by those with depression/anxiety disorder.

Conclusion

Individuals with depression/anxiety disorder were more likely to use telehealth and to do so for reasons of convenience and avoiding infection. Promoting telehealth to those with depression/anxiety disorder should consider their unique utilization patterns.

Burnout and Mental Health in Working Parents: Risk Factors and Practice Implications

INTRODUCTION

Burnout and mental health disorders in parents can have significant implications for families. Little is known about these conditions in working parents. The purpose of this study was to identify the prevalence and mental health risk factors for working parent burnout.

METHOD

De-identified data were collected on a convenience sample of 1285 working parents through an online survey.

RESULTS

Sixty-five percent of working parents reported burnout. Depression, anxiety, attention deficient hyperactivity disorder, abuse, or history of a mental health disorder in the parent were significantly correlated with parental burnout. Anxiety, attention deficient hyperactivity disorder, presence of a mental health disorder in the child, or if parents thought their child might have a mental health disorder were significantly correlated with parent burnout. Parental burnout was significantly associated with greater risk of child maltreatment.

DISCUSSION

This study provides insight into the prevalence and mental health risk factors for parental burnout specific to the working parent.

Providing Quality Family Planning Services in the United States: Recommendations of the U.S. Office of Population Affairs (Revised 2024)

This update, titled Providing Quality Family Planning Servicesa in the United States: Recommendations of the U.S. Office of Population Affairs (Revised 2024), provides recommendations developed by the Office of Population Affairs (OPA) within the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services (HHS). These recommendations represent an update to Providing Quality Family Planning (QFP) Services: Recommendations of the Centers for Disease Control and Prevention (CDC) and the U.S. Office of Population Affairs (OPA), originally published in 2014. The updated recommendations outline how to provide quality sexual and reproductive health (SRH) services for people of reproductive age but can also be used to guide the care of people of any age when the content is relevant to their needs, including family-building services, contraception, pregnancy testing and counseling, early pregnancy management, sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) prevention and testing services, and other preventive health services. The recommendations aim to enable health care providers with the knowledge, skills, and attitudes to ensure that all people, regardless of individual characteristics such as sex, sexual orientation and gender identity, age, disability, or race, can have their SRH needs met. The primary audience for these recommendations is providers and potential providers of SRH services to people of reproductive age, such as providers working in clinical settings dedicated to SRH service delivery, including those funded by the Title X family planning programb as well as primary care providers and other subspecialty providers who may identify SRH needs and make referrals. During the past decade, several changes have taken place in the United States that have affected SRH care delivery, including technological advances, recognition of long-standing inequities, and other legal and regulatory changes. This broader context has been considered in designing the updated recommendations. This update of the QFP aims to provide guidance on the provision of person-centered SRH care focused on individuals' needs, values, and preferences. The update offers specific recommendations for how to provide high-quality SRH care and connects users to relevant guidelines, primary research, and other resources to inform best practices. In addition to incorporating new evidence, this update incorporates newer approaches to care, including adopting a health equity lens that recognizes the impact of structural and interpersonal racism, classism, ableism, and bias based on sexual orientation and/or gender identity on health and the provision of quality SRH care. OPA will update these QFP recommendations periodically to reflect new findings in the scientific literature and revisions to the clinical guidelines referenced in this update.

Country-specific psychopharmacological risk of reporting suicidality comparing 38 antidepressants and lithium from the FDA Adverse Event Reporting System, 2017-2023

Background

The United States Food and Drug Administration (FDA) maintains a black-box warning for antidepressants warning of an increased risk of suicidality in children and young adults that is based on proprietary clinical trial data from study sponsors that were submitted for regulatory approval. This article aimed to assess whether the black-box warning for antidepressants is still valid today using recent drug safety data.

Methods

Post-marketing adverse drug event data were obtained from the US FDA's Adverse Event Reporting System (FAERS) for the years 2017 through 2023. Logistic regression analysis was conducted using the case versus non-case methodology and adjusted for gender, age group, drug role (primary drug, secondary drug, interacting drug, and concomitant drug), initial FDA reporting year, reporter country, and a drug*gene*age group interaction.

Results

In the multivariate analysis, compared to fluoxetine and patients aged 25 to 64 years, children [adjusted reporting odds ratio (aROR) = 7.38, 95% CI, 6.02-9.05] and young adults (aROR = 3.49, 95% CI, 2.65-4.59) were associated with an increased risk of reporting suicidality, but not for the elderly (aROR = 0.76, 95% CI, 0.53-1.09). Relative to fluoxetine, esketamine was associated with the highest rate of reporting suicidality in children (aROR = 3.20, 95% CI, 2.25-4.54); however, esketamine was associated with a lower risk of reporting suicidality in young adults (aROR = 0.59, 95% CI, 0.41-0.84), but not significantly in the elderly (aROR = 0.77, 95% CI, 0.48-1.23). For country-specific findings, relative to the USA, the Slovak Republic, India, and Canada had the lowest risk of reporting suicidality. For the overall study population, desvenlafaxine (aROR = 0.61, 95% CI, 0.46-0.81) and vilazodone (aROR = 0.56, 95% CI, 0.32-0.99) were the only two antidepressants associated with a reduced risk of reporting suicidality.

Conclusion

This study shows that with recent antidepressant drug safety data, the US FDA's black-box warning for prescribing antidepressants to children and young adults is valid today in the USA. However, relative to the USA, 15 countries had a significantly lower risk of reporting suicidality, while 16 countries had a higher risk of reporting suicidality from 38 antidepressants and lithium.

Posttraumatic stress disorder 2 months after cesarean delivery: a multicenter prospective study

BACKGROUND

The prevalence and risk factors of posttraumatic stress disorder after cesarean delivery, outside high-risk contexts, remain unclear.

OBJECTIVE

This study aimed to assess posttraumatic stress disorder prevalence and risk factors at 2 months postpartum among a general population of women with cesarean delivery.

STUDY DESIGN

This was a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, conducted in 27 French hospitals from 2018 to 2020, enrolling women expected to undergo cesarean delivery before or during labor at ≥34 weeks of gestation. After randomization, characteristics of the cesarean delivery and postpartum blood loss were prospectively collected. Two months after childbirth, posttraumatic stress disorder profile (presence of posttraumatic stress disorder symptoms) and provisional diagnosis (positive screening for diagnosis consistent with a posttraumatic stress disorder) were assessed by 2 self-administered questionnaires (Impact of Event Scale - Revised and Traumatic Event Scale). The corrected posttraumatic stress disorder prevalence was estimated with inverse probability weighting to take nonresponse into account. Associations between potential risk factors and posttraumatic stress disorder were analyzed by multivariate logistic or linear regression modeling according to the type of dependent variable.

RESULTS

In total, 2785 of 4431 women returned the Impact of Event Scale - Revised questionnaire and 2792 the Traumatic Event Scale (response rates of 62.9% and 63.0%). The prevalence of posttraumatic stress disorder profile was 9.0% (95% confidence interval, 7.8%-10.3%) and of provisional diagnosis 1.7% (95% confidence interval, 1.2%-2.4%). Characteristics associated with a higher risk of posttraumatic stress disorder profile were prepregnancy vulnerability factors (young age, high body mass index, and African-born migrant) and cesarean delivery-related obstetrical factors (cesarean delivery after induced labor [adjusted odds ratio, 1.81; 95% confidence interval, 1.14-2.87], postpartum hemorrhage [adjusted odds ratio, 1.61; 95% confidence interval, 1.04-2.46] and high-intensity pain during the postpartum stay [adjusted odds ratio, 1.90; 95% confidence interval, 1.17-3.11]). Women who had immediate skin-to-skin contact with their newborn were at lower risk of posttraumatic stress disorder (adjusted odds ratio, 0.66; 95% confidence interval, 0.46-0.98), and women with bad memories of delivery on day 2 postpartum were at higher risk (adjusted odds ratio, 3.20; 95% confidence interval, 1.97-5.12). The Impact of Event Scale - Revised and the Traumatic Event Scale yielded consistent results.

CONCLUSION

Approximately 1 in 11 women with cesarean deliveries had posttraumatic stress disorder symptoms at 2 months postpartum. Some obstetrical interventions and components of cesarean delivery management may influence this risk.

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

BACKGROUND

Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement.

METHODS

Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates.

RESULTS

Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms.

CONCLUSIONS

Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Evaluating mental health support by healthcare providers for patients with atopic dermatitis: A cross-sectional survey

Importance

Atopic dermatitis (AD) is associated with psychosocial symptoms, resulting in significant mental health burden and reduced quality of life.

Objective

To understand mental health support received by patients from their primary eczema provider.

Design

We administered a cross-sectional survey (N = 954) to US caregivers and adult patients with AD.

Setting

The National Eczema Association (United States) conducted an online survey in October 2022 among self-selected patients and caregivers.

Outcome

Patients and caregivers of AD patients reported on mental health conversations and types of mental health support received by their/their child's provider.

Results

Many patients did not discuss (41.9%) or were not asked (50.5%) about their mental health by their eczema provider, and 64% reported not receiving a mental health referral. Patients were more likely to receive mental health support if they were male (2.00 [1.08-3.69]), low or middle education level (4.89 [2.10-11.36], 2.71 [1.36-5.40]), or had purchased insurance policies (4.43 [1.79-10.98]). Providers were most likely to refer patients to counseling services (22.5%), followed by alternative mental health therapy (14.9%), cognitive behavioural therapy (13.3%) and peer/social support groups (12.2%).

Conclusion

Despite the strong association between AD and mental health conditions, there is a significant proportion of patients that report not receiving mental health support from their/their child's primary eczema provider. Screening with validated measures may improve the identification of patients requiring additional support. Future research should evaluate the efficacy of mental health resources and barriers to accessing and referring patients for mental health care.

Bidirectional Associations Between Mental Health Disorders and Chronic Diabetic Complications in Individuals With Type 1 or Type 2 Diabetes

OBJECTIVE

To determine bidirectional associations between the timing of chronic diabetes complications (CDCs) and mental health disorders (MHDs) in individuals with type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

We used a nationally representative health care claims database to identify matched individuals with type 1 or 2 diabetes or without diabetes using a propensity score quasirandomization technique stratified by age (0-19, 20-39, 40-59, and ≥60 years). CDCs and MHDs were identified using ICD-9/10 codes. We fit Cox proportional hazards models with time-varying diagnoses of CDCs or MHDs to investigate their association with the hazard of developing MHDs or CDCs, respectively.

RESULTS

From 2001 to 2018, a total of 553,552 individuals were included (44,735 with type 1 diabetes, 152,187 with type 2 diabetes, and 356,630 without diabetes). We found that having a CDC increased the hazard of developing an MHD (hazard ratio [HR] 1.9-2.9; P < 0.05, with higher HRs in older age strata), and having an MHD increased the hazard of developing a CDC (HR 1.4-2.5; P < 0.05, with the highest HR in age stratum 0-19 years). In those aged <60 years, individuals with type 1 diabetes were more likely to have CDCs, whereas individuals with type 2 diabetes were more likely to have MHDs. However, the relationship between CDCs and MHDs in either direction was not affected by diabetes type (P > 0.05 for interaction effects).

CONCLUSIONS

We found a consistent bidirectional association between CDCs and MHDs across the life span, highlighting the important relationship between CDCs and MHDs. Prevention and treatment of either comorbidity may help reduce the risk of developing the other.

Generalized anxiety disorder screening scores are associated with greater treatment need among Veterans with depression

Comorbid anxiety and depression predict a poorer prognosis than either disorder occurring alone. It is unclear whether self-reported anxiety symptom scores identify patients with depression in need of more intensive mental health services. This study evaluated how anxiety symptoms predicted treatment receipt and outcomes among patients with new depression diagnoses in the Veterans Health Administration (VHA). Electronic medical record data from 128,917 VHA patients (71.6% assessed for anxiety, n = 92,237) with new diagnoses of depression were analyzed to examine how Generalized Anxiety Disorder-7 (GAD-7) scores predicted psychotropic medication prescriptions, psychotherapy receipt, acute care service utilization, and follow-up depression symptoms. Patients who reported severe symptoms of anxiety were significantly more likely to receive adequate acute phase and continuation phase antidepressant treatment, daytime anxiolytics/sedatives, nighttime sedative/hypnotics, and endorse more severe depression symptoms and suicidal ideation at follow-up. Patients who reported severe symptoms of anxiety at baseline were less likely to initiate psychotherapy. The GAD-7 may help identify depressed patients who have more severe disease burden and require additional mental health services.

Comparing the effect of two systems-level interventions on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms

BACKGROUND

The Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms are designed to help obstetric practices address perinatal depression. The PRogram in Support of Moms includes the statewide Massachusetts Child Psychiatry Access Program for Moms program, plus proactive implementation support.

OBJECTIVE

The goal of this study was to understand the impact of these programs on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms among individuals screening positive for depression.

STUDY DESIGN

We conducted a secondary analysis of 2017-2022 data from a cluster randomized controlled trial of Massachusetts Child Psychiatry Access Program for Moms vs PRogram In Support of Moms. We included participants completing a generalized anxiety disorder or posttraumatic stress disorder screen at baseline (n=254) with antenatal Edinburgh Postnatal Depression Scale scores ≥10. We assessed changes in generalized anxiety disorder and posttraumatic stress disorder symptoms from pregnancy (4-25 weeks of gestational age or 32-40 weeks of gestational age), 4-12 weeks postpartum, and 11-13 months postpartum. We conducted a difference-in-difference analysis to compare symptom change from pregnancy to postpartum. We used adjusted linear mixed models with repeated measures to examine the impact of the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms on changes in the Generalized Anxiety Disorder 7 and the Posttraumatic Stress Disorder Checklist.

RESULTS

Mean Generalized Anxiety Disorder 7 scores decreased by 3.6 (Massachusetts Child Psychiatry Access Program for Moms) and 6.3 (PRogram In Support of Moms) points from pregnancy to 4-12 weeks postpartum. Mean Posttraumatic Stress Disorder Checklist scores decreased by 6.2 and 10.0 points, respectively, at 4-12 weeks postpartum among individuals scree ning positive on the Generalized Anxiety Disorder 7 (n=83) or Posttraumatic Stress Disorder Checklist (n=58) in pregnancy. Generalized Anxiety Disorder 7 and Posttraumatic Stress Disorder Checklist scores decreased among both groups at 11-13 months postpartum. These changes were clinically meaningful. PRogram In Support of Moms conferred a statistically significant greater decrease (2.7 points) on the Generalized Anxiety Disorder 7 than the Massachusetts Child Psychiatry Access Program for Moms at 4-12 weeks postpartum. No differences were found between the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms in Posttraumatic Stress Disorder Checklist or Generalized Anxiety Disorder 7 change at 11-13 months, although both were associated with a reduction in generalized anxiety disorder and posttraumatic stress disorder symptoms at 4-12 weeks and 11-13 months postpartum.

CONCLUSION

Both the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms could help to improve symptoms for individuals experiencing co-occurring symptoms of depression, generalized anxiety disorder, or posttraumatic stress disorder. PRogram In Support of Moms may confer additional benefits in the early postpartum period, although this difference was not clinically significant.

Anxiety symptoms predict head and neck cancer survival: Exploring mediation by systemic inflammation and tumor response to treatment

BACKGROUND

Head and neck cancers (HNC) are associated with high rates of anxiety. Anxiety has been linked to biological pathways implicated in cancer progression, though little is known about its effects on overall survival. We hypothesized that higher pretreatment anxiety levels in patients with HNC would predict poorer 2-year overall survival and expected this relationship to be mediated by both systemic inflammation and tumor response to treatment.

METHODS

Patients (N = 394) reported anxiety symptomatology via the GAD-7 at treatment planning. Pre-treatment hematology workup provided an index of systemic inflammation (SII; N = 292). Clinical data review yielded tumor response and overall survival. Logistic and multiple regressions and Cox proportional hazard models tested hypothesized relationships.

RESULTS

Higher pretreatment anxiety levels were significantly associated with poorer 2-year survival (hazard ratio [HR], 1.039; 95% confidence interval [CI], 1.014-1.066, p = 0.002). The association between anxiety and SII was not significant, though anxiety was associated with poorer tumor response (odds ratio [OR], 1.033; 95% CI, 1.001-1.066, p = 0.043). Tumor response fully mediated the relationship between anxiety symptoms and 2-year survival (HR, 9.290, 95% CI, 6.152-14.031, p < 0.001).

CONCLUSIONS

Anxiety was associated with overall survival. Tumor response, but not systemic inflammation, emerged as a potential biological pathway mediating this effect. Screening for anxiety may be beneficial to help prospectively address these concerns and ameliorate potentially detrimental impact on clinically meaningful cancer outcomes.

How much or how often? Examining the screening properties of the DSM cross-cutting symptom measure in a youth population-based sample

BACKGROUND

The DSM Level 1 Cross-Cutting Symptom Measure (DSM-XC) allows for assessing multiple psychopathological domains. However, its capability to screen for mental disorders in a population-based sample and the impact of adverbial framings (intensity and frequency) on its performance are unknown.

METHODS

The study was based on cross-sectional data from the 1993 Pelotas birth cohort in Brazil. Participants with completed DSM-XC and structured diagnostic interviews (n = 3578, aged 22, 53.6% females) were included. Sensitivity, specificity, positive (LR+), and negative (LR-) likelihood ratios for each of the 13 DSM-XC domains were estimated for detecting five internalizing disorders (bipolar, generalized anxiety, major depressive, post-traumatic stress, and social anxiety disorders) and three externalizing disorders (antisocial personality, attention-deficit/hyperactivity, and alcohol use disorders). Sensitivities and specificities >0.75, LR+ > 2 and LR- < 0.5 were considered meaningful. Values were calculated for the DSM-XC's original scoring and for adverbial framings.

RESULTS

Several DSM-XC domains demonstrated meaningful screening properties. The anxiety domain exhibited acceptable sensitivity and LR- values for all internalizing disorders. The suicidal ideation, psychosis, memory, repetitive thoughts and behaviors, and dissociation domains displayed acceptable specificity for all disorders. Domains also yielded small but meaningful LR+ values for internalizing disorders. However, LR+ and LR- values were not generally meaningful for externalizing disorders. Frequency-framed questions improved screening properties.

CONCLUSIONS

The DSM-XC domains showed transdiagnostic screening properties, providing small but meaningful changes in the likelihood of internalizing disorders in the community, which can be improved by asking frequency of symptoms compared to intensity. The DSM-XC is currently lacking meaningful domains for externalizing disorders.

Evaluation of the efficacy, safety, and pharmacokinetics of nanodispersible cannabidiol oral solution (150 mg/mL) versus placebo in mild to moderate anxiety subjects: A double blind multicenter randomized clinical trial

BACKGROUND

Anxiety disorders, an increasingly prevalent global mental health illness, affected approximately 301 million individuals worldwide in 2019. There is an unmet need for the treatment of anxiety disorders, as current therapies are associated with limited response rates, residual symptoms, and adverse effects.

OBJECTIVES

To evaluate the efficacy, safety, and pharmacokinetics of nanodispersible cannabidiol (CBD) oral solution versus placebo for the treatment of mild to moderate anxiety disorders.

METHODS

This phase 3 prospective, randomized, double blind, parallel group, placebo-controlled, 15-week cohort study took place at multiple sites across India. Eligible participants were randomly assigned to one of the two treatment arms (CBD or placebo) in a 1:1 ratio.

RESULTS

178 participants were randomized to receive CBD (n=89) or placebo (n=89). The study met both primary (GAD-7 and HAM-A scores) and secondary outcomes (CGI-I, CGI-S, PHQ-9 and PSQI scores). The GAD-7 score difference between the end of treatment and baseline for the CBD versus the placebo was -7.02 (S.E: 0.25, 95% CI -7.52; -6.52), p<0.0001. Similarly, the HAM-A score difference at the end of treatment compared to baseline for the CBD versus the placebo was -11.9 (S.E: 0.33, 95% CI -12.6; -11.3), p<0.0001.

CONCLUSIONS

Nanodispersible CBD was therapeutically safe with no serious adverse events, well tolerated, and effective for the treatment of mild to moderate anxiety disorders, as well as associated depression and sleep quality disturbances. These results pave way for probable prospective use of nanodispersible CBD formulation for various psychiatry disorders alone or in conjunction with other drugs.

Internalizing Psychiatric Symptoms in People with Mosaicism for Trisomy 21

People with mosaicism for trisomy 21 have been shown to exhibit the many of same phenotypic traits present in people with non-mosaic Down syndrome, but with varying symptom severity. However, the behavioral phenotype of people with mosaic Down syndrome (mDS) has not been well characterized. This study aimed to examine the prevalence of self-report and caregiver-report symptoms of depression and anxiety among a sample of 62 participants with mDS aged 12 - 46, and assess their association with the percentage of trisomy 21 in blood and/or buccal mucosa cells. The results showed that 53% of the participants reported clinically significant depression symptoms and 76% reported clinically significant anxiety symptoms. No clear associations were observed between the percentage of trisomic cells and total anxiety or depression, but a significant positive association between the proband-reported specific fears subscale and the percentage of trisomic cells in buccal specimens was detected (r = .43, p = .007). This study highlights the high occurrence of depression and anxiety symptoms in individuals with mDS and the need for routine assessment to optimize their care. It also demonstrates the ability of people with mDS to complete these evaluations, thereby supporting their inclusion in research studies/clinical trials.

Associations of Anxiety Symptoms With 6-Year Blood Pressure Changes and Incident Hypertension: Results From the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Despite the high burden of anxiety and hypertension in Hispanic/Latino adults, little is known about their association in this population.

PURPOSE

To examine the associations of anxiety symptoms with 6-year changes in blood pressure (BP) and incident hypertension in Hispanic/Latino adults.

METHODS

We examined data from a probability sample of 10,881 Hispanic/Latino persons aged 18-74 who attended visits 1 (V1; 2008-2011) and 2 (V2; 2014-2017) of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a prospective cohort study. Anxiety symptoms were assessed at V1 using the 10-item Spielberger Trait Anxiety Scale (M = 17.1; Range = 10-40) and dichotomized using a cut-point of 20, the highest quartile in this cohort. BP was measured at both visits using a standardized protocol.

RESULTS

Adults with elevated anxiety symptoms had a 1.02 mm Hg greater increase in systolic (p = .02) and a 0.75 mm Hg greater increase in diastolic BP (p = .02) over 6.1 years than those with lower symptoms, after adjusting for sociodemographic and clinical covariates. These associations differed by sex. Elevated anxiety was associated with a greater increase in systolic and diastolic BP in men only. Among persons without hypertension at V1 (N = 7,412), those with elevated anxiety symptoms at V1 had a 22% higher incidence of hypertension (p = .02) 6.1 years later.

CONCLUSIONS

Our findings underscore the importance of screening for and treating elevated anxiety symptoms to help prevent hypertension. Further research on the role of sex and underlying mechanisms is warranted.

Sleep Health and Anxiety Symptoms in Midlife Women: The Study of Women's Health Across the Nation (SWAN)

Purpose

To investigate the associations between anxiety symptoms in midlife women and sleep features later in life, the aim is to test the hypothesis that poor sleep, as measured by each of six individual dimensions (4 objective actigraphy measures, 2 self-reports) of sleep health, is associated with higher levels of anxiety symptoms in midlife women.

Participants and Methods

The participants in this longitudinal analysis included women from the SWAN Sleep I Study, a subcohort of the community-dwelling midlife women participating in the core Study of Women's Health Across the Nation (SWAN), which was initiated in 1996. Of the 370 participants enrolled in the Sleep Study, 270 were included in the analytic sample, and 100 who did not meet the inclusion criteria were excluded. Baseline measures of six dimensions of multidimensional sleep health (actigraphy measures: efficiency, duration, mid-sleep timing, regularity; self-report measures: alertness, satisfaction) were obtained between 2003 and 2005, corresponding to SWAN core annual/biennial assessments 5-8. Associations of each dimension with self-reported anxiety symptoms (Generalized Anxiety Disorder - 7-item scale; GAD-7), collected during visits 12 (2009-2011), 13 (2011-2013), and 15 (2015-2017), were examined using mixed models. The GAD-7 outcome was measured both continuously and as a categorical variable due to its skewed distribution.

Results

No statistically significant associations were found between any of the six baseline sleep health dimensions and the GAD-7 score after adjustment for covariates.

Conclusion

The reasons for the lack of support for our hypothesis, despite previous evidence supporting an association between sleep and anxiety, are unclear. There is considerable overlap between anxiety and sleep symptoms, which may complicate the interpretation of our the findings. Thus, the failure to identify associations is likely multifactorial, and more studies with shorter follow-up intervals are warranted to better understand these relationships.

Polygenic liability for anxiety in association with comorbid anxiety in multiple sclerosis

OBJECTIVE

Comorbid anxiety occurs often in MS and is associated with disability progression. Polygenic scores offer a possible means of anxiety risk prediction but often have not been validated outside the original discovery population. We aimed to investigate the association between the Generalized Anxiety Disorder 2-item scale polygenic score with anxiety in MS.

METHODS

Using a case-control design, participants from Canadian, UK Biobank, and United States cohorts were grouped into cases (MS/comorbid anxiety) or controls (MS/no anxiety, anxiety/no immune disease or healthy). We used multiple anxiety measures: current symptoms, lifetime interview-diagnosed, and lifetime self-report physician-diagnosed. The polygenic score was computed for current anxiety symptoms using summary statistics from a previous genome-wide association study and was tested using regression.

RESULTS

A total of 71,343 individuals of European genetic ancestry were used: Canada (n = 334; 212 MS), UK Biobank (n = 70,431; 1,390 MS), and the USA (n = 578 MS). Meta-analyses identified that in MS, each 1-SD increase in the polygenic score was associated with ~50% increased odds of comorbid moderate anxious symptoms compared to those with less than moderate anxious symptoms (OR: 1.47, 95% CI: 1.09-1.99). We found a similar direction of effects in the other measures. MS had a similar anxiety genetic burden compared to people with anxiety as the index disease.

INTERPRETATION

Higher genetic burden for anxiety was associated with significantly increased odds of moderate anxious symptoms in MS of European genetic ancestry which did not differ from those with anxiety and no comorbid immune disease. This study suggests a genetic basis for anxiety in MS.

Trauma exposure across the lifespan among individuals engaged in treatment with medication for opioid use disorder: differences by gender, PTSD status, and chronic pain

BACKGROUND

There is little study of lifetime trauma exposure among individuals engaged in medication treatment for opioid use disorder (MOUD). A multisite study provided the opportunity to examine the prevalence of lifetime trauma and differences by gender, PTSD status, and chronic pain.

METHODS

A cross-sectional study examined baseline data from participants (N = 303) enrolled in a randomized controlled trial of a mind-body intervention as an adjunct to MOUD. All participants were stabilized on MOUD. Measures included the Trauma Life Events Questionnaire (TLEQ), the Brief Pain Inventory (BPI), and the Posttraumatic Stress Disorder Checklist (PCL-5). Analyses involved descriptive statistics, independent sample t-tests, and linear and logistic regression.

RESULTS

Participants were self-identified as women (n = 157), men (n = 144), and non-binary (n = 2). Fifty-seven percent (n = 172) self-reported chronic pain, and 41% (n = 124) scored above the screening cut-off for PTSD. Women reported significantly more intimate partner violence (85%) vs 73%) and adult sexual assault (57% vs 13%), while men reported more physical assault (81% vs 61%) and witnessing trauma (66% vs 48%). Men and women experienced substantial childhood physical abuse, witnessed intimate partner violence as children, and reported an equivalent exposure to accidents as adults. The number of traumatic events predicted PTSD symptom severity and PTSD diagnostic status. Participants with chronic pain, compared to those without chronic pain, had significantly more traumatic events in childhood (85% vs 75%).

CONCLUSION

The study found a high prevalence of lifetime trauma among people in MOUD. Results highlight the need for comprehensive assessment and mental health services to address trauma among those in MOUD treatment.

TRIAL REGISTRATION

NCT04082637.

Effects of Two Group Prenatal Care Interventions on Mental Health: An RCT

INTRODUCTION

Perinatal depression and anxiety cost the U.S. health system $102 million annually and result in adverse health outcomes. Research supports that cognitive behavioral therapy improves these conditions, but barriers to obtaining cognitive behavioral therapy have prevented its success in pregnant individuals. In this study, the impact of a cognitive behavioral therapy-based intervention on anxiety, depression, stress, healthy lifestyle beliefs, and behaviors in pregnant people was examined.

STUDY DESIGN

This study used a 2-arm RCT design, embedded in group prenatal care, with one arm receiving a cognitive behavioral therapy-based Creating Opportunities for Personal Empowerment program and the other receiving health promotion content.

SETTING/PARTICIPANTS

Black and Hispanic participants (n=299) receiving prenatal care from 2018 to 2022 in New York and Ohio who screened high on 1 of 3 mental health measures were eligible to participate.

INTERVENTION

Participants were randomized into the manualized Creating Opportunities for Personal Empowerment cognitive behavioral therapy-based program, with cognitive behavioral skill-building activities delivered by advanced practice nurses in the obstetrical setting.

MAIN OUTCOME MEASURES

Outcomes included anxiety, depression, and stress symptoms using valid and reliable tools (Generalized Anxiety Disorder scale, Edinburgh Postnatal Depression Scale, and Perceived Stress Scale). The Healthy Lifestyle Beliefs and Behaviors Scales examined beliefs about maintaining a healthy lifestyle and reported healthy behaviors.

RESULTS

There were no statistically significant differences between groups in anxiety, depression, stress, healthy beliefs, and behaviors. There were significant improvements in all measures over time. There were statistically significant decreases in anxiety, depression, and stress from baseline to intervention end, whereas healthy beliefs and behaviors significantly increased.

CONCLUSIONS

Both cognitive behavioral therapy and health promotion content embedded in group prenatal care with advanced practice nurse delivery improved mental health and healthy lifestyle beliefs and behaviors at a time when perinatal mood generally worsens.

TRIAL REGISTRATION

This study is registered with clinicaltrials.gov NCT03416010.

Hematopoietic Stem Cells as an Integrative Hub Linking Lifestyle to Cardiovascular Health

Despite breakthroughs in modern medical care, the incidence of cardiovascular disease (CVD) is even more prevalent globally. Increasing epidemiologic evidence indicates that emerging cardiovascular risk factors arising from the modern lifestyle, including psychosocial stress, sleep problems, unhealthy diet patterns, physical inactivity/sedentary behavior, alcohol consumption, and tobacco smoking, contribute significantly to this worldwide epidemic, while its underpinning mechanisms are enigmatic. Hematological and immune systems were recently demonstrated to play integrative roles in linking lifestyle to cardiovascular health. In particular, alterations in hematopoietic stem cell (HSC) homeostasis, which is usually characterized by proliferation, expansion, mobilization, megakaryocyte/myeloid-biased differentiation, and/or the pro-inflammatory priming of HSCs, have been shown to be involved in the persistent overproduction of pro-inflammatory myeloid leukocytes and platelets, the cellular protagonists of cardiovascular inflammation and thrombosis, respectively. Furthermore, certain lifestyle factors, such as a healthy diet pattern and physical exercise, have been documented to exert cardiovascular protective effects through promoting quiescence, bone marrow retention, balanced differentiation, and/or the anti-inflammatory priming of HSCs. Here, we review the current understanding of and progression in research on the mechanistic interrelationships among lifestyle, HSC homeostasis, and cardiovascular health. Given that adhering to a healthy lifestyle has become a mainstream primary preventative approach to lowering the cardiovascular burden, unmasking the causal links between lifestyle and cardiovascular health from the perspective of hematopoiesis would open new opportunities to prevent and treat CVD in the present age.

Brainwide Mendelian Randomization Study of Anxiety Disorders and Symptoms

BACKGROUND

To gain insights into the role of brain structure and function on anxiety (ANX), we conducted a genetically informed investigation leveraging information from ANX genome-wide association studies available from the UK Biobank (n = 380,379), the FinnGen Program (n = 290,361), and the Million Veteran Program (n = 175,163) together with UK Biobank genome-wide data (n = 33,224) related to 3935 brain imaging-derived phenotypes (IDPs).

METHODS

A genetic correlation analysis between ANX and brain IDPs was performed using linkage disequilibrium score regression. To investigate ANX-brain associations, a 2-sample Mendelian randomization was performed considering multiple methods and sensitivity analyses. A subsequent multivariable Mendelian randomization was conducted to distinguish between direct and indirect effects. Finally, a generalized linear model was used to explore the associations of brain IDPs with ANX symptoms.

RESULTS

After false discovery rate correction (q < .05), we identified 41 brain IDPs genetically correlated with ANX without heterogeneity among the datasets investigated (i.e., UK Biobank, FinnGen, and Million Veteran Program). Six of these IDPs showed genetically inferred causal effects on ANX. In the subsequent multivariable Mendelian randomization analysis, reduced area of the right posterior middle cingulate gyrus (β = -0.09, p = 8.01 × 10-4) and reduced gray matter volume of the right anterior superior temporal gyrus (β = -0.09, p = 1.55 × 10-3) had direct effects on ANX. In the ANX symptom-level analysis, the right posterior middle cingulate gyrus was negatively associated with "tense, sore, or aching muscles during the worst period of anxiety" (β = -0.13, p = 8.26 × 10-6).

CONCLUSIONS

This study identified genetically inferred effects that are generalizable across large cohorts, thereby contributing to our understanding of how changes in brain structure and function can lead to ANX.

Care trajectories of individuals with anxiety disorders: A retrospective cohort study

BACKGROUND

Anxiety disorders (ADs) are associated with increased healthcare use (HCU), and individuals may seek healthcare through various pathways according to clinical and individual characteristics. This study aimed to characterize care trajectories (CTs) of individuals with ADs.

METHODS

This is a retrospective cohort study using the Care Trajectories - Enriched Data cohort, a linkage between the Canadian Community Health Surveys (CCHS), and health administrative data from Quebec. The cohort included 5143 respondents reporting ADs to the CCHS between 2009 and 2016. We measured CTs over 5 years before CCHS using a state sequence analysis.

RESULTS

The cohort was categorized into five types of CTs. Type 1 (52.7 %) was the lowest care-seeking group, with fewer comorbidities. Type 2 (24.0 %) had higher levels of physical and mental health comorbidities and moderate HCU, mainly ambulatory visits to general practitioners. Type 3 (13.1 %) represented older patients with the highest level of physical illnesses and high HCU, predominantly ambulatory consultation of specialists other than psychiatrists. Types 4 and 5 combined young and middle-aged patients suffering from severe psychological distress. HCU of type 4 (6.7 %) was high, mainly consultations of ambulatory psychiatrists, and HCU of type 5 (3.5 %), was the highest and mostly in acute care.

LIMITATIONS

Administrative and survey data may have coding errors, missing data and self-report biases.

CONCLUSION

Five types of CTs showed distinct patterns of HCU often modulated by physical and mental health comorbidities, which emphasizes the importance of considering ADs when individuals seek care for other mental health conditions or physical illness.

Generalized anxiety and mild anxiety symptoms in U.S. military veterans: Prevalence, characteristics, and functioning

Generalized anxiety disorder (GAD) is a mental disorder characterized by excessive anxiety and worries that impair daily functioning. While prior work has documented the prevalence and correlates of GAD and subthreshold GAD (SGAD) in clinical samples, contemporary data on the epidemiology of anxiety symptoms are lacking, particularly in higher-risk populations such as military veterans. To address this gap, we analyzed data from a large, nationally representative sample of U.S. veterans to examine the: prevalence of probable GAD and mild anxiety symptoms measured using a brief screener; sociodemographic and military characteristics associated with anxiety symptoms; and psychiatric and functional correlates of anxiety symptoms. Results revealed that a total of 7.9% (95% confidence interval [CI] = 6.7-9.3%) and 22.1% (95%CI = 20.5-23.9%) of veterans screened positive for probable GAD and mild anxiety symptoms, respectively. Relative to veterans without anxiety symptoms, those with probable GAD and mild anxiety symptoms were younger, more likely to be female and racial/ethnic minorities, and more likely to have served 2+ deployments. Further, a "dose-response" association was observed between anxiety symptom severity and clinical correlates, with robust associations observed between probable GAD and poorer mental health, suicidal thoughts and behaviors, and functional impairment. Mild anxiety symptoms showed intermediate magnitude associations with these outcomes. Results of this study suggest that 3-of-10 U.S. veterans report anxiety symptoms. While the use of a brief screener to assess mild anxiety symptoms and probable GAD is limited, findings underscore the importance of a dimensional approach to assessing anxiety symptoms and associated clinical and functional characteristics in veterans.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study

BACKGROUND

Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030.

METHODS AND FINDINGS

Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts.

CONCLUSIONS

The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

Trauma Exposure Across the Lifespan among Individuals Engaged in Treatment with Medication for Opioid Use Disorder: Differences by Gender, PTSD Status, and Chronic Pain

Background

There is little study of lifetime trauma exposure among individuals engaged in medication treatment for opioid use disorder (MOUD). A multisite study provided the opportunity to examine the prevalence of lifetime trauma and differences by gender, PTSD status, and chronic pain.

Methods

A cross-sectional study examined baseline data from participants (N = 303) enrolled in a randomized controlled trial of a mind-body intervention as an adjunct to MOUD. All participants were stabilized on MOUD. Measures included the Trauma Life Events Questionnaire (TLEQ), the Brief Pain Inventory (BPI), and the Posttraumatic Stress Disorder Checklist (PCL-5). Analyses involved descriptive statistics, independent sample t-tests, and linear and logistic regression.

Results

Participants were self-identified as women (n = 157), men (n = 144), and non-binary (n = 2). Fifty-seven percent (n = 172) self-reported chronic pain, and 41% (n = 124) scored above the screening cut-off for PTSD. Women reported significantly more intimate partner violence (85%) vs 73%) and adult sexual assault (57% vs 13%), while men reported more physical assault (81% vs 61%) and witnessing trauma (66% vs 48%). Men and women experienced substantial childhood physical abuse, witnessed intimate partner violence as children, and reported an equivalent exposure to accidents as adults. The number of traumatic events predicted PTSD symptom severity and PTSD diagnostic status. Participants with chronic pain, compared to those without chronic pain, had significantly more traumatic events in childhood (85% vs 75%).

Conclusions

The study found a high prevalence of lifetime trauma among people in MOUD. Results highlight the need for comprehensive assessment and mental health services to address trauma among those in MOUD treatment.

Trial Registration

NCT04082637.

Depression, anxiety, and stress in pregnant Black people: A case for screening and evidence-based intervention

BACKGROUND

Guidelines call for pregnant people to be screened for depression and anxiety. Screening may be particularly important for pregnant Black individuals who are reported to be more likely than non-Hispanic White pregnant people to experience prenatal stress, anxiety, and depressive symptoms. The purpose of this study was to determine if depression, anxiety, and stress co-occur in pregnant Black people and to identify which demographic factors are related to these mental health concerns.

METHODS

A subset analysis of an ongoing randomized controlled trial examined the risk of coexisting mental health conditions in pregnant Black people who screened eligible to participate (that is, they had high levels of depression, anxiety, and/or stress) in two urban clinics using a descriptive correlational design.

RESULTS

Of the 452 pregnant Black people who were screened for eligibility, 194 (42.9%) had elevated scores on depression, anxiety, and/or stress measures and were enrolled in the larger study. The average scores of the 194 enrolled participants were anxiety, mean (M) = 9.16 (standard deviation [SD] = 4.30); depression, M = 12.80 (SD = 4.27); and stress, M = 21.79 (SD = 4.76). More than one-third (n = 70, 36.1%) experienced two symptoms and 64 (33.0%) reported all three symptoms.

CONCLUSION

Pregnant Black individuals experience high levels of comorbid mental health distress including depression, anxiety, and stress. The findings indicate that treatment for mental health concerns needs to be broad-based and effective for all three conditions. Prenatal interventions should aim to address mental health distress through screening and treatment of depression, anxiety, and stress, especially for pregnant Black individuals. This study furthers understanding of the prevalence of prenatal mental health conditions in pregnant Black people.

The Association of Psychological Variants with Back Pain, Muscle Endurance, and Functional Limitations in an Individual with Chronic Back Pain

Chronic low back pain (CLBP) substantially impacts quality of life through a multifarious interplay of physical and psychological elements. A comprehensive understanding of this relationship is imperative for developing effective treatment strategies. This study recruited 64 participants (35 males and 29 females) experiencing chronic low back pain to explore the associations between psychological factors, muscle endurance, and functional impairments. The study was conducted over six months in an outpatient department and a rehabilitation unit. The study utilized established outcome measures, such as the Biering-Sorensen Test and the Roland Morris Disability Questionnaire, and psychological variants as the core dependent variables, including the Beck Depression Inventory (BDI), STAI questionnaire, the FABQ-PA, and the Pain Catastrophizing Scale (PCS). The findings uncovered pronounced gender disparities, with females exhibiting elevated levels of depression (BDI: 27.68 ± 9.43, p < 0.001) and anxiety (STAI: 42.34 ± 8.94, p < 0.001) and diminished muscle endurance (130.47 ± 30.56 sec, p = 0.001). These revelations are congruent with the prevailing literature, emphasizing the need for gender-sensitive and personalized interventions. Bivariate correlations presented robust associations between psychological distress and decreased muscle endurance (r values ranging from -0.82 to -0.88, p < 0.001) alongside elevated functional impairments (r values from 0.89 to 0.94, p < 0.001) for both genders. Additionally, linear regression analyses illuminated the consequential impact of specific psychological variables such as the BDI, FABQ-PA, and PCS on muscle endurance and functional impairments (all p < 0.001). This study reveals gender-specific variations in chronic back pain, highlighting the influence of psychological factors on pain perception. It underscores the necessity for gender-sensitive treatment strategies. Future research is needed to explore these differences further and assess treatment efficacy to improve care and quality of life for chronic low back pain sufferers through personalized treatment plans.

Mental health and care utilization in survivors of adolescent and young adult cancer

BACKGROUND

Adolescent and young adult cancer survivors experience mental health challenges, yet little is known about the evolution of these difficulties. This study explored mental health symptoms and utilization among long-term adolescent and young adult cancer survivors.

METHODS

Using 30 432 respondents from the 2019 National Health Interview Survey, this study compared adults with a history of adolescent and young adult cancer (diagnosed when patients were between 15 and 39 years of age) to adults without adolescent and young adult cancer. Mental health symptom severity was measured using the Patient Health Questionnaire depression scale and 7-item Generalized Anxiety Disorder questionnaires. Care utilization constituted psychotherapy and mental health medication use. Inverse propensity score weights were used to balance demographics and combined with survey weights. Descriptive statistics, multivariable generalized linear models, and structural equation modeling with 2-sided tests were used for analysis.

RESULTS

We compared 639 adolescent and young adult survivors with 29 793 controls. Survivors were, on average, 20.5 years (SE = 0.74) past their cancer diagnosis dates. After adjusting for survey and propensity score weights, adolescent and young adult survivors reported more severe depression (incidence rate ratio = 1.42, 95% confidence interval [CI] = 1.09 to 1.84, P < .01) and anxiety (incidence rate ratio = 1.85, 95% CI = 1.55 to 2.21, P < .001). They were more likely to use psychotherapy (odds ratio = 1.91, 95% CI = 1.16 to 3.17, P < .05) and mental health medications (odds ratio = 1.89, 95% CI = 1.15 to 3.11, P < .05). Time since diagnosis was negatively associated with symptoms and utilization. Structural equation modeling demonstrated mediation of utilization effect by symptom severity.

CONCLUSIONS

Adolescent and young adult survivors experience worse mental health in late survivorship, despite small improvements over time. We highlight the importance of survivorship care that addresses the long-term mental health needs of these survivors.

Brain-Wide Mendelian Randomization Study of Anxiety Disorders and Symptoms

Background

To gain insights into the role of brain structure and function on anxiety (ANX), we conducted a genetically informed investigation leveraging information from ANX genome-wide association studies available from UK Biobank (UKB; N=380,379), FinnGen Program (N=290,361), and Million Veteran Program (MVP; N=199,611) together with UKB genome-wide data (N=33,224) related to 3,935 brain imaging-derived phenotypes (IDP).

Methods

A genetic correlation analysis between ANX and brain IDPs was performed using linkage disequilibrium score regression. To investigate ANX-brain associations, a two-sample Mendelian randomization (MR) was performed considering multiple methods and sensitivity analyses. A subsequent multivariable MR (MVMR) was executed to distinguish between direct and indirect effects. Finally, a generalized linear model was used to explore the associations of brain IDPs with ANX symptoms.

Results

After false discovery rate correction (FDR q<0.05), we identified 41 brain IDPs genetically correlated with ANX without heterogeneity among the datasets investigated (i.e., UKB, FinnGen, and MVP). Six of these IDPs showed genetically inferred causal effects on ANX. In the subsequent MVMR analysis, reduced area of the right posterior middle-cingulate gyrus (rpMCG; beta=-0.09, P= 8.01×10 -4 ) and reduced gray-matter volume of the right anterior superior temporal gyrus (raSTG; beta=-0.09, P=1.55×10 -3 ) had direct effects on ANX. In the ANX symptom-level analysis, rpMCG was negatively associated with "tense sore oraching muscles during the worst period of anxiety" (beta=-0.13, P=8.26×10 -6 ).

Conclusions

This study identified genetically inferred effects generalizable across large cohorts, contributing to understand how changes in brain structure and function can lead to ANX.