Sample selection may bias the outcome of an adolescent mental health survey: results from a five-year follow-up of 4171 adolescents

An investigation into symptoms of depression and anxiety and emotion regulation among older adolescents from low-income settings in South Africa

INTRODUCTION

Mental health conditions (MHC) among adolescents in low- and middle-income countries, including South Africa, are estimated to be high. Adaptive emotion regulation (ER) skills can protect against MHC among adolescents. In South Africa, there is limited adolescent mental health prevalence data as well as little understanding of the associations between MHC and ER among adolescents. This study aimed to address these gaps by describing the psychosocial characteristics of older South African adolescents from low-income settings as well as investigating associations between depression and anxiety symptoms and ER.

METHODS

We selected 12 schools in collaboration with two NGOs. Learners aged 15-18-years were recruited to complete a tablet-based survey. ER, depression, anxiety, and other psychosocial measures were included. Two multiple linear regression models were used to determine associations between depression symptoms, anxiety symptoms, other psychosocial factors, and ER.

RESULTS

Of the 733 participants from 12 Western Cape schools, 417 (56.90%) screened at risk for clinically significant anxiety symptoms, 423 (57.70%) participants for depression symptoms, 229 (31.40%) participants for PTSD symptoms and 263 (35.90%) for risky alcohol use. Depression and anxiety scores were found to be significantly positively correlated with ER difficulties and adolescents struggled most with identifying and utilizing adaptive ER strategies. The adjusted linear regression model reported that female gender, clinically significant depressive, anxiety, post-traumatic stress symptoms and risky-alcohol use were all significantly associated with poorer ER scores, while self-esteem was significantly associated with better ER scores.

CONCLUSION

These findings contribute to the South African adolescent mental health literature and to the research gap on the links between depression and anxiety and ER. Future research should consider further exploration of the relationships between psychosocial factors and ER to inform the urgent development and testing of appropriate adolescent interventions in this setting.

Experiences of stigma, discrimination and violence and their impact on the mental health of health care workers during the COVID-19 pandemic

Health care workers have been exposed to COVID-19 more than people in other professions, which may have led to stigmatization, discrimination, and violence toward them, possibly impacting their mental health. We investigated (1) factors associated with stigma, discrimination, and violence, (2) the association of stigma, discrimination, and violence with mental health, (3) everyday experiences of stigmatization, discrimination, and violence. We chose a combination of a quantitative approach and qualitative content analysis to analyze data collected at three time points: in 2020, 2021 and 2022. A higher age was associated with lower odds of experiencing stigma, discrimination, and violence, whereas female gender was related to more negative experiences. The intensity of exposure to COVID-19 was associated with greater experience with stigmatization, discrimination, and violence across all three years (for example in 2022: odds ratio, 95% confidence interval: 1.74, 1.18-2.55 for mild exposure; 2.82, 1.95-4.09 for moderate exposure; and 5.74, 3.55-9.26 for severe exposure, when compared to no exposure). Stigma, discrimination, and violence were most strongly associated with psychological distress in 2020 (odds ratio = 2.97, 95% confidence interval 2.27-3.88) and with depressive symptoms in 2021 (odds ratio = 2.78, 95% confidence interval 2.12-3.64). Attention should be given to the destigmatization of contagious diseases and the prevention of discrimination, violence, and mental health problems, both within workplaces and among the public.

Sociodemographic, mental health, and physical health factors associated with participation within re-contactable mental health cohorts: an investigation of the GLAD Study

BACKGROUND

The Genetic Links to Anxiety and Depression (GLAD) Study is a large cohort of individuals with lifetime anxiety and/or depression, designed to facilitate re-contact of participants for mental health research. At the start of the pandemic, participants from three cohorts, including the GLAD Study, were invited to join the COVID-19 Psychiatry and Neurological Genetics (COPING) study to monitor mental and neurological health. However, previous research suggests that participation in longitudinal studies follows a systematic, rather than random, process, which can ultimately bias results. Therefore, this study assessed participation biases following the re-contact of GLAD Study participants.

METHODS

In April 2020, all current GLAD Study participants (N = 36,770) were invited to the COPING study. Using logistic regression, we investigated whether sociodemographic, mental, and physical health characteristics were associated with participation in the COPING baseline survey (aim one). Subsequently, we used a zero-inflated negative binomial regression to examine whether these factors were also related to participation in the COPING follow-up surveys (aim two).

RESULTS

For aim one, older age, female gender identity, non-binary or self-defined gender identities, having one or more physical health disorders, and providing a saliva kit for the GLAD Study were associated with an increased odds of completing the COPING baseline survey. In contrast, lower educational attainment, Asian or Asian British ethnic identity, Black or Black British ethnic identity, higher alcohol consumption at the GLAD sign-up survey, and current or ex-smoking were associated with a reduced odds. For aim two, older age, female gender, and saliva kit provision were associated with greater COPING follow-up survey completion. Lower educational attainment, higher alcohol consumption at the GLAD Study sign-up, ex-smoking, and self-reported attention deficit hyperactivity disorder had negative relationships.

CONCLUSIONS

Participation biases surrounding sociodemographic and physical health characteristics were particularly evident when re-contacting the GLAD Study volunteers. Factors associated with participation may vary depending on study design. Researchers should examine the barriers and mechanisms underlying participation bias in order to combat these issues and address recruitment biases in future studies.

Cortical thickness is inversely associated with transcranial magnetic stimulation-evoked N45 potential among young adults whose heavy drinking began in adolescence

BACKGROUND

Adolescence is a particularly vulnerable stage of development in terms of the deleterious effects of alcohol. Both lower gray matter (GM) volume and greater GABAergic activity have been associated with chronic alcohol consumption during adolescence. However, the association between these measures has not been investigated.

METHODS

In this exploratory study, we compared 26 young adults with a 10year history of heavy alcohol consumption with 21 controls who used little or no alcohol. Simultaneous transcranial magnetic stimulation and electroencephalography were used to assess transcranial magnetic stimulation-evoked N45 potentials, reflecting a balance between GABAergic inhibition and N-methyl-D-aspartate (NMDA) receptor-mediated glutaminergic excitation in the brain. GM thickness was measured from magnetic resonance images and GM and N45 potentials were then correlated.

RESULTS

Cortical thickness was significantly lower in several brain regions in the heavy-drinking group than the light-drinking group. The N45 amplitude was significantly larger frontally in the heavy-drinking group. Among heavy drinkers, there were several statistically significant correlations between thinner GM and larger frontal N45 amplitudes that were not detectable in the light-drinking group. The strongest correlations were detected in the frontal and parietal lobes, especially in the left superior frontal gyrus and the left supramarginal gyrus, and in both hemispheres in the superior parietal lobes.

CONCLUSIONS

These findings show that a thinner cortex and greater inhibitory neurotransmission are correlated in certain brain regions among young, long-term heavy alcohol users. Studies are needed to explore the possible causal mechanisms underlying these effects.

Exploring potential for selection bias in using survey data to estimate the association between institutional trust and depression

PURPOSE

We tested the hypothesis that low institutional trust would be associated with depressive symptom elevation, with attention to potential selection bias.

METHODS

The District of Columbia Area Survey (DCAS) was conducted by mail in 2018. Invitations sent to 8800 households resulted in a sample of 1061 adults. Institutional trust questions referenced nonprofit organizations, businesses, and government. Depressive symptom elevation was assessed using PHQ-9. Logistic regression model estimates were compared with and without adjustment for sociodemographic characteristics and neighborhood satisfaction; among complete cases and following multiple imputation of missing covariate data; and with and without survey weights or correction for collider selection bias.

RESULTS

Of 968 participants without missing depressive symptom or trust data, 24% reported low institutional trust. Low institutional trust was associated with elevated depressive symptoms (adjusted OR following multiple imputation: 2.0; 95% CI: 1.1, 3.4), although the association was attenuated with use of survey weights (adjusted OR incorporating multiple imputation and survey weights: 1.6; 95% CI: 0.7, 3.2).

CONCLUSIONS

Under contrasting scenarios where low institutional trust and depressive symptoms jointly increase nonresponse, selection bias could lead to under- or overestimation of this association. Future research could explore posited selection bias scenarios that differ in direction of bias.

Stability of alexithymia is low from adolescence to young adulthood, and the consistency of alexithymia is associated with symptoms of depression and dissociation

BACKGROUND

The aims of this study were to investigate the stability of alexithymia from adolescence to young adulthood, as well as the association between alexithymia, peer relationships, and symptoms of depression and dissociation.

METHODS

The participants (n = 755, aged 13-18 years) were assessed with self-rated questionnaires and the 20-item Toronto Alexithymia Scale (TAS-20) at baseline in 2005 and on follow-up in 2011.

RESULTS

The changes in the TAS-20 total score (t = -12.26) and the scores for its subscales, difficulty identifying feelings (DIF) (t = -4.04), difficulty describing feelings (DDF) (t = -5.10), and externally oriented thinking (EOT) (t = -18.23), were statistically significant (p < 0.001). Effect sizes (Cohen's d) for the change indicating absolute stability were small for DIF (-0.15) and DDF (-0.19), medium for TAS-20 total (-0.45), and large for EOT (-0.66) scores. Moderate correlations in test-retests with Spearman's ρ (TAS-20 total 0.46, DIF 0.41, DDF 0.39, EOT 0.43) indicated relative stability, whereas low intraclass correlation coefficients (ICCs) (respectively 0.41, 0.39, 0.37, 0.37) indicated poor reliability of test-retests. In regression analyses, poor relationships with peers, loneliness, and symptoms of depression and dissociation at baseline associated with alexithymia at baseline and on follow-up. Unlike EOT, increases in the TAS-20 total, DIF, and DDF scores during the 6-year follow-up associated with baseline symptoms of depression and dissociation.

CONCLUSIONS

Alexithymia in adolescence is not always a reliable predictor of alexithymia in young adulthood. Mental health symptoms appear to affect the consistency of alexithymia during adolescent development.

Social support may prevent self-cutting in adolescence: A 5-year follow-up study

Self-cutting is common among adolescents. However, studies examining protective factors are rare. It has been suggested that social support may protect against self-cutting in adolescence. The aim of this study was to investigate the possible association of social relationships with the initiation of self-cutting.

METHODS

The participants were community-dwelling Finnish adolescents (N = 4171) aged 13-18 years at baseline. The follow-up assessment was conducted 5 years later (N = 794). Those adolescents who had self-cut before the baseline assessment (N = 134) were excluded from the analysis, leaving a total of 660 participants to be analyzed. In this group, 37 adolescents initiated self-cutting during the 5-year follow-up period and 623 did not. Cox's proportional hazards models were used with several adjustments for possible confounding factors.

FINDINGS

A higher age, male gender, good relationships with siblings, weekly meetings with friends, and personal experience of not being lonely associated with the noninitiation of self-cutting during the follow-up period. Good relationships with parents or peers had no association with the initiation of self-cutting. Depressive symptoms mediated the effect of subjective loneliness on initiating self-cutting.

CONCLUSIONS

Social support produced by friends may have a protective effect against self-cutting.

Heavy drinking from adolescence to young adulthood is associated with an altered cerebellum

Excessive alcohol use results in cerebellar damage in adults, but there has been less research on how alcohol use during adolescence affects the cerebellum. In this study, we observed that heavy drinking from adolescence to young adulthood was associated with altered volumes of cerebellar lobules. The study included two groups consisting of 33 heavy-drinking and 25 light-drinking participants. The heavy-drinking participants were highly functional young adults without alcohol use disorder, but with a history of regular heavy alcohol consumption. The participants were 13-18 years old at baseline and were followed for 10 years. At the age of 21-28 years, the participants underwent magnetic resonance imaging (MRI). From the MR images, the cerebellum was segmented into 12 lobules using the CERES pipeline. Heavy drinking did not influence the absolute cerebellar volume, but changes were observed in posterior cerebellar lobules associated with motor and cognitive functions. The absolute volume (p = 0.038) and gray matter volume (p = 0.034) of Crus II (hemispheres combined) were smaller in the heavy-drinking group. Furthermore, the relative volume of the right VIIIB lobule was larger in the HD group (p = 0.036). However, there were no differences in the absolute right VIIIB volumes (p = 0.198) between the groups. Our results suggest changes in the cerebellum in healthy young adults with a history of heavy drinking from adolescence. The exact implications and significance of these findings require further research.

Changes in the serum metabolite profile correlate with decreased brain gray matter volume in moderate-to-heavy drinking young adults

Our aim was to analyze metabolite profile changes in serum associated with moderate-to-heavy consumption of alcohol in young adults and to evaluate whether these changes are connected to reduced brain gray matter volumes. These study population consisted of young adults with a 10-year history of moderate-to-heavy alcohol consumption (n = 35) and light-drinking controls (n = 27). We used the targeted liquid chromatography mass spectrometry method to measure concentrations of metabolites in serum, and 3.0 T magnetic resonance imaging to assess brain gray matter volumes. Alterations in amino acid and energy metabolism were observed in the moderate-to-heavy drinking young adults when compared to the controls. After correction for multiple testing, the group of moderate-to-heavy drinking young adults had increased serum concentrations of 1-methylhistamine (p = 0.001, d = 0.82) when compared to the controls. Furthermore, concentrations of 1-methylhistamine (r = -0.48, p = 0.004) and creatine (r = -0.52, p = 0.001) were negatively correlated with the brain gray matter volumes in the females. Overall, our results show association between moderate-to-heavy use of alcohol and altered metabolite profile in young adults as well as suggesting that some of these changes could be associated with the reduced brain gray matter volume.

Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients?

OBJECTIVES

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels.

METHODS

This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital.

RESULTS

Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost.

CONCLUSIONS

Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.

Experiences of sexual harassment are associated with the sexual behavior of 14- to 18-year-old adolescents

Subjection to sexual harassment is associated with a number of negative outcomes, such as internalizing and externalizing symptoms and a disinclination to attend school. Among adolescents, sexual harassment may increase with both their emerging sexual desires and increased socializing in mixed-gender peer groups during early adolescence. We set out to study the possible associations between normative and risk-taking sexual behavior and subjection to sexual harassment among adolescents between the ages of 14 and 18 years. The informants included 90,953 boys and 91,746 girls, with a mean (SD) age of 16.3 (1.2) years, who responded to a classroom survey (School Health Promotion Study 2010-2011) in Finland. We found that even early steps in romantic and erotic experiences were associated with experiences of sexual harassment. The more advanced the adolescents' sexual experiences were, the more commonly they reported differing experiences of sexual harassment. These associations were particularly strong among the girls. Among the sexually active adolescents, the more partners the adolescents had for intercourse, the more commonly they reported experiences of sexual harassment. Adolescents actively interested in romantic and sexual relationships may socialize in contexts where sexual harassment is more likely to occur. They may be more sensitive to sexual cues than their non-interested peers, or sexual harassment may be a traumatic experience predisposing adolescents to risk-taking sexual behavior as a form of acting out. A double standard regarding the appropriate expression of sexuality received some support in our data.

Heavy alcohol use in adolescence is associated with altered cortical activity: a combined TMS-EEG study

Long-term alcohol use affects cognitive and neurophysiological functioning as well as structural brain development. Combining simultaneous electroencephalogram (EEG) recording with transcranial magnetic stimulation (TMS) enables direct, in vivo exploration of cortical excitability and assessment of effective and functional connectivity. In the central nervous system, the effects of alcohol are particularly mediated by alterations in gamma-aminobutyric acid (GABA)ergic neurotransmission, and TMS-evoked potentials (TEPs) N45 and N100 in EEG are known to reflect GABAergic function. However, no previous studies have examined the effects of long-term alcohol use in adolescence on TEPs. In this study, a total of 27 young adults with heavy alcohol use in adolescence and 25 age-matched, gender-matched and education-matched controls with little or no alcohol use participated in TMS-EEG measurements. The motor cortex (M1) was stimulated with an intensity of 90 percent of the resting motor threshold of the abductor pollicis brevis muscle. No significant differences were found in the resting motor threshold, TEP latencies or neuropsychological functioning between the groups. We observed an increase in the global mean field power in the time window of 54- to 75-millisecond post-TMS, as well as significant topographical differences in the P60 and N100 in those with a history of heavy drinking. Furthermore, there was a marked increase in the GABAergic N45 amplitude in alcohol users. These findings suggest that long-term alcohol use in adolescence, even when not meeting the diagnostic criteria for a disorder, is associated with changes in connectivity and cortical excitability.

Alcohol consumption during adolescence is associated with reduced grey matter volumes

BACKGROUND AND AIMS

Cognitive impairment has been associated with excessive alcohol use, but its neural basis is poorly understood. Chronic excessive alcohol use in adolescence may lead to neuronal loss and volumetric changes in the brain. Our objective was to compare the grey matter volumes of heavy- and light-drinking adolescents.

DESIGN

This was a longitudinal study: heavy-drinking adolescents without an alcohol use disorder and their light-drinking controls were followed-up for 10 years using questionnaires at three time-points. Magnetic resonance imaging was conducted at the last time-point.

SETTING

The area near Kuopio University Hospital, Finland.

PARTICIPANTS

The 62 participants were aged 22-28 years and included 35 alcohol users and 27 controls who had been followed-up for approximately 10 years.

MEASUREMENTS

Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT)-C at three time-points during 10 years. Participants were selected based on their AUDIT-C score. Magnetic resonance imaging was conducted at the last time-point. Grey matter volume was determined and compared between heavy- and light-drinking groups using voxel-based morphometry on three-dimensional T1-weighted magnetic resonance images using predefined regions of interest and a threshold of P < 0.05, with small volume correction applied on cluster level.

FINDINGS

Grey matter volumes were significantly smaller among heavy-drinking participants in the bilateral anterior cingulate cortex, right orbitofrontal and frontopolar cortex, right superior temporal gyrus and right insular cortex compared to the control group (P < 0.05, family-wise error-corrected cluster level).

CONCLUSIONS

Excessive alcohol use during adolescence appears to be associated with an abnormal development of the brain grey matter. Moreover, the structural changes detected in the insula of alcohol users may reflect a reduced sensitivity to alcohol's negative subjective effects.