Reward and Punishment Learning as Predictors of Cognitive Behavioral Therapy Response in Parkinson's Disease Comorbid with Clinical Depression

Depression is highly comorbid among individuals with Parkinson's Disease (PD), who often experience unique challenges to accessing and benefitting from empirically supported interventions like Cognitive Behavioral Therapy (CBT). Given the role of reward processing in both depression and PD, this study analyzed a subset (N = 25) of participants who participated in a pilot telemedicine intervention of PD-informed CBT, and also completed a Reward- and Punishment-Learning Task (RPLT) at baseline. At the conclusion of CBT, participants were categorized into treatment responders (n = 14) and non-responders (n = 11). Responders learned more optimally from negative rather than positive feedback on the RPLT, while this pattern was reversed in non-responders. Computational modeling suggested group differences in learning rate to negative feedback may drive the observed differences. Overall, the results suggest that a within-subject bias for punishment-based learning might help to predict response to CBT intervention for depression in those with PD.Plain Language Summary Performance on a Computerized Task may predict which Parkinson's Disease Patients benefit from Cognitive Behavioral Treatment of Clinical DepressionWhy was the study done? Clinical depression regularly arises in individuals with Parkinson's Disease (PD) due to the neurobiological changes with the onset and progression of the disease as well as the unique psychosocial difficulties associated with living with a chronic condition. Nonetheless, psychiatric disorders among individuals with PD are often underdiagnosed and likewise undertreated for a variety of reasons. The results of our study have implications about how to improve the accuracy and specificity of mental health treatment recommendations in the future to maximize benefits for individuals with PD, who often face additional barriers to accessing quality mental health treatment.What did the researchers do? We explored whether performance on a computerized task called the Reward- and Punishment-Learning Task (RPLT) helped to predict response to Cognitive Behavioral Therapy (CBT) for depression better than other predictors identified in previous studies. Twenty-five individuals with PD and clinical depression that completed a 10-week telehealth CBT program were assessed for: Demographics (Age, gender, etc.); Clinical information (PD duration, mental health diagnoses, levels of anxiety/depression, etc.); Neurocognitive performance (Memory, processing speed, impulse control, etc.); and RPLT performance.What did the researchers find? A total of 14 participants significantly benefitted from CBT treatment while 11 did not significantly benefit from treatment.There were no differences before treatment in the demographics, clinical information, and neurocognitive performance of those participants who ended up benefitting from the treatment versus those who did not.There were, however, differences before treatment in RPLT performance so that those individuals that benefitted from CBT seemed to learn better from negative feedback.What do the findings mean? Our results suggest that the CBT program benefitted those PD patients with clinical depression that seemed to overall learn best from avoiding punishment rather than obtaining reward which was targeted in CBT by focusing on increasing engagement in rewarding activities. The Reward- and Punishment-Learning Task hence may be a useful tool to help predict treatment response and provide more individualized recommendations on how to best maximize the benefits of psychotherapy for individuals with PD that may struggle to connect to mental health care. Caution is recommended about interpretating these results beyond this study as the overall number of participants was small and the data for this study were collected as part of a previous study so there was no opportunity to include additional measurements of interest.

Impairment in recognition memory may be associated with near-term risk for suicide attempt in a high-risk sample

INTRODUCTION

Prior work has implicated several neurocognitive domains, including memory, in patients with a history of prior suicide attempt. The current study evaluated whether a delayed recognition test could enhance prospective prediction of near-term suicide outcomes in a sample of patients at high-risk for suicide.

METHODS

132 Veterans at high-risk for suicide completed a computer-based recognition memory test including semantically-related and -unrelated words. Outcomes were coded as actual suicide attempt (ASA), other suicide-related event (OtherSE) such as aborted/interrupted attempt or preparatory behavior, or neither (noSE), within 90 days after testing.

RESULTS

Reduced performance was a significant predictor of upcoming ASA, but not OtherSE, after controlling for standard clinical variables such as current suicidal ideation and history of prior suicide attempt. However, compared to the noSE reference group, the OtherSE group showed a reduction in the expected benefit of semantic relatedness in recognizing familiar words. A computational model, the drift diffusion model (DDM), to explore latent cognitive processes, revealed the OtherSE group had decreased decisional efficiency for semantically-related compared to semantically-unrelated familiar words.

LIMITATIONS

This study was a secondary analysis of an existing dataset, involving participants in a treatment trial, and requires replication; ~10 % of the sample was excluded from analysis due to failure to master the practice tasks and/or apparent noncompliance.

CONCLUSION

Impairments in recognition memory may be associated with near-term risk for suicide attempt, and may provide a tool to improve prediction of when at-risk individuals may be transitioning into a period of heightened risk for suicide attempt.

Clinical significance of psychotic-like experiences across U.S. ethnoracial groups

BACKGROUND

Prevalence of psychotic-like experiences (PLEs) - reports of hallucinations and delusional thinking not meeting criteria for psychotic disorder - varies substantially across ethnoracial groups. What explains this range of PLE prevalence? Despite extensive research, the clinical significance of PLEs remains unclear. Are PLE prevalence and clinical severity differentially associated across ethnoracial groups?

METHODS

We examined the lifetime prevalence and clinical significance of PLEs across ethnoracial groups in the Collaborative Psychiatric Epidemiology Surveys (N = 11 139) using the Composite International Diagnostic Interview (CIDI) psychosis symptom screener. Outcomes included mental healthcare use (inpatient, outpatient), mental health morbidity (self-perceived poor/fair mental health, suicidal ideation or attempts), and impairment (role interference). Individuals with outcome onsets prior to PLE onset were excluded. We also examined associations of PLEs with CIDI diagnoses. Cox proportional-hazards regression and logistic regression modeling identified associations of interest.

RESULTS

Contrary to previous reports, only Asian Americans differed significantly from other U.S. ethnoracial groups, reporting lower lifetime prevalence (6.7% v. 8.0-11.9%) and mean number (0.09 v. 0.11-0.18) of PLEs. In multivariate analyses, PLE clinical significance showed limited ethnoracial variation among Asian Americans, non-Caribbean Latinos, and Afro-Caribbeans. In other groups, mental health outcomes showed significant ethnoracial clustering by outcome (e.g. hospitalization and role interference with Caribbean-Latino origin), possibly due to underlying differences in psychiatric disorder chronicity or treatment barriers.

CONCLUSIONS

While there is limited ethnoracial variation in U.S. PLE prevalence, PLE clinical significance varies across U.S. ethnoracial groups. Clinicians should consider this variation when assessing PLEs to avoid exaggerating their clinical significance, contributing to mental healthcare disparities.

Social Control and Health Behaviors Among Individuals Living with Parkinson's Disease: A Pilot Study

BACKGROUND

Positive health behaviors (e.g., exercise, healthy eating habits, good sleep hygiene, treatment adherence) are important in ensuring optimal symptom management and health outcomes among individuals living with Parkinson's disease (PD). While multiple factors may influence engagement in health behaviors, little is known about the occurrence of social control, or relationship partners' attempts to influence and regulate another's behavior, and its potential role in the adoption of health behaviors among individuals with PD.

METHODS

To better understand the types of social control attempts employed and begin to explore the association between social control attempts and behavioral responses (e.g., engage in the targeted health behavior, hide the behavior) to those attempts, survey data were drawn from a cross-sectional, pilot study of married/partnered Veterans diagnosed with idiopathic PD (n = 25). Participants completed self-reported measures of sociodemographics, physical and mental well-being, relationship functioning, and both the frequency of and behavioral responses to positive and negative social control attempts.

RESULTS

Although the majority of individuals reported their partners engaged in positive social control attempts, half also reported negative attempts. Bivariate analyses revealed more frequent positive social control attempts from one's partner were related to both positive and negative behavioral responses, and negative social control attempts were related to negative behavioral responses. However, when adjusting for covariates, positive social control attempts were related to positive behavioral responses, while negative social exchanges with one's partner (e.g., general conflict), rather than exposure to negative social control attempts, were related to negative behavioral responses.

CONCLUSIONS

Findings lend preliminary evidence of the relationship between social control and exchanges and health behavior that may inform future, adequately powered observational and intervention studies that target interpersonal processes and health behaviors among individuals living with PD and their relationship partners.

Improving the prospective prediction of a near-term suicide attempt in veterans at risk for suicide, using a go/no-go task

BACKGROUND

Neurocognitive testing may advance the goal of predicting near-term suicide risk. The current study examined whether performance on a Go/No-go (GNG) task, and computational modeling to extract latent cognitive variables, could enhance prediction of suicide attempts within next 90 days, among individuals at high-risk for suicide.

METHOD

136 Veterans at high-risk for suicide previously completed a computer-based GNG task requiring rapid responding (Go) to target stimuli, while withholding responses (No-go) to infrequent foil stimuli; behavioral variables included false alarms to foils (failure to inhibit) and missed responses to targets. We conducted a secondary analysis of these data, with outcomes defined as actual suicide attempt (ASA), other suicide-related event (OtherSE) such as interrupted/aborted attempt or preparatory behavior, or neither (noSE), within 90-days after GNG testing, to examine whether GNG variables could improve ASA prediction over standard clinical variables. A computational model (linear ballistic accumulator, LBA) was also applied, to elucidate cognitive mechanisms underlying group differences.

RESULTS

On GNG, increased miss rate selectively predicted ASA, while increased false alarm rate predicted OtherSE (without ASA) within the 90-day follow-up window. In LBA modeling, ASA (but not OtherSE) was associated with decreases in decisional efficiency to targets, suggesting differences in the evidence accumulation process were specifically associated with upcoming ASA.

CONCLUSIONS

These findings suggest that GNG may improve prediction of near-term suicide risk, with distinct behavioral patterns in those who will attempt suicide within the next 90 days. Computational modeling suggests qualitative differences in cognition in individuals at near-term risk of suicide attempt.

A Pilot Study of Telehealth Mindfulness-Based Cognitive Therapy for Depression in Parkinson's Disease

Introduction: Parkinson's disease (PD) is characterized by high-rates of depression with limited evidence-based treatment options to improve mood. Objective: To expand therapeutic options, we evaluated the feasibility and effect of a telehealth mindfulness-based cognitive therapy intervention adapted for PD (MBCT-PD) in a sample of participants with DSM-5 depressive disorders. Methods: Fifteen participants with PD and clinically-significant depression completed 9 sessions of MBCT-PD. Depression, anxiety, and quality of life were evaluated at baseline, endpoint, and 1-month follow-up. Results: Telehealth MBCT-PD was feasible and beneficial. Completion rates exceeded 85% and treatment satisfaction rates were high. Notable improvements were observed for depression, anxiety, and quality of life over the course of the trial. Conclusion: Telehealth MBCT-PD shows promise and warrants further evaluation via randomized clinical trial with more diverse participants. Such research holds the potential to expand the range of therapeutic options for depression in PD, thereby setting the stage for personalized care.

A practical introduction to using the drift diffusion model of decision-making in cognitive psychology, neuroscience, and health sciences

Recent years have seen a rapid increase in the number of studies using evidence-accumulation models (such as the drift diffusion model, DDM) in the fields of psychology and neuroscience. These models go beyond observed behavior to extract descriptions of latent cognitive processes that have been linked to different brain substrates. Accordingly, it is important for psychology and neuroscience researchers to be able to understand published findings based on these models. However, many articles using (and explaining) these models assume that the reader already has a fairly deep understanding of (and interest in) the computational and mathematical underpinnings, which may limit many readers' ability to understand the results and appreciate the implications. The goal of this article is therefore to provide a practical introduction to the DDM and its application to behavioral data - without requiring a deep background in mathematics or computational modeling. The article discusses the basic ideas underpinning the DDM, and explains the way that DDM results are normally presented and evaluated. It also provides a step-by-step example of how the DDM is implemented and used on an example dataset, and discusses methods for model validation and for presenting (and evaluating) model results. Supplementary material provides R code for all examples, along with the sample dataset described in the text, to allow interested readers to replicate the examples themselves. The article is primarily targeted at psychologists, neuroscientists, and health professionals with a background in experimental cognitive psychology and/or cognitive neuroscience, who are interested in understanding how DDMs are used in the literature, as well as some who may to go on to apply these approaches in their own work.

Criticism in the Parkinson's Caregiving Relationship: A Key Target for Intervention

INTRODUCTION

Caregiver distress is prevalent in Parkinson's disease (PD) and predictive of negative health outcomes for both people with PD and caregivers. To identify future intervention targets, it is important to better elucidate the specific processes, such as criticism, that perpetuate burden.

OBJECTIVE

Evaluate the frequency and impact of criticism and reactivity to criticism in PD caregiving dyads.

METHODS

Eighty-three people with PD and their caregivers independently completed measures of criticism and physical and emotional health.

RESULTS

Criticism in the caregiving relationship was reported by 71.1% (n = 59) of people with PD and 80.7% (n = 67) of caregivers. Both perceived criticism and emotional reactivity to criticism were significant predictors of caregiver distress, adjusting for PD motor and non-motor symptom severity. In contrast, criticism was not related to PD depression.

CONCLUSION

Criticism in the PD caregiving relationship is a clear target for psychotherapeutic intervention and may improve caregiver health and quality of life.

Attentional control may be modifiable with Mindfulness-Based Cognitive Therapy to Prevent Suicide

OBJECTIVE

To test whether Mindfulness-Based Cognitive Therapy to Prevent Suicide (MBCT-S) is associated with improvement in attentional control, an objective marker of suicide attempt.

METHOD

In the context of a randomized clinical trial targeting suicide risk in Veterans, computerized Stroop and emotion Stroop (E-Stroop) tasks were administered 3 times over 6-months follow-up to 135 high suicide risk Veterans. Seventy were randomized to receive MBCT-S in addition to enhanced treatment as usual (eTAU), and 65 were randomized to eTAU only. E-Stroop word types included positively- and negatively-valenced emotion, suicide, and combat-related words. Interference scores and mixed effects linear regression analyses were used.

RESULTS

Veterans receiving MBCT-S showed a more favorable trajectory of attentional control over time, as indicated by performance on two E-Stroop tasks. Combat-stress interference scores improved over time among Veterans in MBCT-S. Interference processing time for negative affective words deteriorated over time among Veterans receiving eTAU only.

CONCLUSIONS

MBCT-S may effectively target attentional control, and in particular reduce processing time during affective interference, in high suicide risk Veterans. Future studies to replicate these findings are warranted.

Mindfulness-Based Cognitive Therapy for Preventing Suicide in Military Veterans: A Randomized Clinical Trial

Objective: This study evaluated whether Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S) effectively augmented treatment-as-usual enhanced for suicide prevention (eTAU).

Methods: From December 2013 through March 2018, veterans (N = 140) at high risk for suicide were recruited mostly (88.6%) during a suicide-related inpatient admission and randomly assigned to either (1) eTAU augmented with MBCT-S or (2) eTAU only. MBCT-S began during inpatient treatment (2 individual sessions emphasizing safety planning) and continued post-discharge (8 group sessions emphasizing mindfulness skills and elaborated safety planning). Four follow-up evaluations occurred over 12 months, and primary outcomes were (1) time to suicide event and (2) number of suicide events. Secondary outcomes were time to and number of suicide attempts, proportion with acute psychiatric hospitalization, and change in suicide-related factors (eg, depression, hopelessness, suicidal ideation).

Results: Relative to eTAU, MBCT-S did not significantly delay time to suicide event (hazard ratio = 0.86; 95% CI, 0.52-1.41; P = .54), but did reduce total number of suicide events (MBCT-S: 56 events; eTAU: 92 events; incident rate ratio = 0.59; 95% CI, 0.36-0.99; P < .05). There were no significant differences in time to or number of suicide attempts. In a post hoc analysis, however, MBCT-S significantly reduced the proportion of participants attempting suicide (P < .05). MBCT-S also reduced the proportion with a psychiatric hospitalization. No significant between-group differences emerged on any suicide-related factors.

Conclusions: Adding MBCT-S to system-wide suicide prevention efforts produced mixed findings on the primary outcome (suicide events) and promising findings on other important outcomes (suicide attempts, psychiatric hospitalizations). MBCT-S should continue to be examined in future research.

Trial Registration: ClinicalTrials.gov identifier: NCT01872338.

Coping with Suicidal Urges: An Important Factor for Suicide Risk Assessment and Intervention

Suicide-related coping refers to strategies for adaptively managing suicidal urges and can be important an important factor for assessing risk and targeting intervention. The current study evaluated whether suicide-related coping predicted a suicidal event within 90-days, independently of other known risk factors. Veterans (N = 64) were evaluated shortly after a suicidal crisis and completed several assessments, including a measure of suicide-related coping. Multivariate analyses showed that suicide-related coping remained protective of a suicidal event (OR = 0.93; p = .047) after adjusting for suicidal ideation, previous suicide attempts, mood disorder, distress tolerance, and gender. Suicide-related coping may augment commonly assessed clinical factors in prediction of a suicidal event and is a suitable target for suicide prevention efforts.

Innovating Parkinson's Care: A Randomized Controlled Trial of Telemedicine Depression Treatment

BACKGROUND

For several decades, a myriad of factors have contributed to the inadequate diagnosis and management of depression in Parkinson's disease (PD), leaving up to 60% of significantly symptomatic patients untreated. Poor access to evidence-based neuropsychiatric care is one major barrier to achieving optimal Parkinson's outcomes.

OBJECTIVE

The goal of this study was to compare the efficacy of individual Parkinson's-informed, video-to-home cognitive-behavioral therapy (experimental group), to clinic-based treatment as usual (control group), for depression in PD.

METHOD

Ninety United States military veterans with clinical diagnoses of both depression and PD were computer-randomized (1:1) to either the experimental or control group; randomization was stratified by baseline antidepressant use and blind to all other baseline data. The acute treatment period spanned 10 weeks and was followed by a 6-month extension phase. The Hamilton Depression Rating Scale was the a priori primary outcome. Depression treatment response was defined as a score ≤2 on the Clinical Global Impression Improvement Scale. All statistical analyses were intent to treat.

RESULTS

Video-to-home cognitive-behavioral therapy outperformed clinic-based treatment as usual across three separate depression measures (P < 0.001). Effects were observed at the end of acute treatment and maintained through 6-month follow-up. Number needed to treat (based on treatment response classification) was 2.5 with an absolute risk reduction of 40%.

CONCLUSION

Video-to-home cognitive-behavioral therapy may be an effective intervention to bypass access barriers to specialized, evidence-based depression care in PD and to address the unmet neuropsychiatric treatment needs of the Parkinson's community. © 2021 International Parkinson and Movement Disorder Society.

Towards the objective assessment of suicidal states: Some neurocognitive deficits may be temporally related to suicide attempt

Neurocognitive detection of suicidal states has the potential to significantly advance objective risk assessment. This goal requires establishing that neurocognitive deficits fluctuate around the time of a suicide attempt. The current study therefore evaluated whether neurocognitive performance is temporally related to suicide attempt, in a sample at highrisk for suicide (n = 141). Evaluations consisted of a clinician-administered interview, self-report questionnaires, and neurocognitive tasks assessing response inhibition, attentional control, and memory recognition. Analyses examined whether neurocognitive scores significantly differed according to the following temporal suicide attempt categories: (a) past-week attempt; (b) past-year attempt (not in past week); and (c) no past-year attempt. Univariate results showed that response inhibition and memory recognition were significantly related to suicide attempt recency. Post-hoc pairwise tests showed that participants with a past-week suicide attempt showed greater impairments than those without a past-year attempt. Multivariate tests showed the same pattern of results, adjusting for age, suicide attempts prior to past year, mood disturbance, and suicidal ideation. These results show that neurocognitive assessment of response inhibition and memory recognition shows sensitivity to the recency of a suicide attempt. While future prospective studies are needed, results suggest that phasic neurocognitive deficits may serve as objective markers of short-term suicide risk.

Telephone-based cognitive behavioral therapy for depression in Parkinson disease: A randomized controlled trial

Objective

To determine whether, for patients with depression and Parkinson disease (PD), telephone-based cognitive-behavioral treatment (T-CBT) alleviates depressive symptoms significantly more than treatment as usual (TAU), we conducted a randomized controlled trial to evaluate the efficacy of a 10-session T-CBT intervention for depression in PD, compared to TAU.

Methods

Seventy-two people with PD (PWP) were randomized to T-CBT + TAU or TAU only. T-CBT tailored to PWPs’ unique needs was provided weekly for 3 months, then monthly during 6-month follow-up. CBT targeted negative thoughts (e.g., “I have no control”; “I am helpless”) and behaviors (e.g., social withdrawal, excessive worry). It also trained care partners to help PWP practice healthy habits. Blind raters assessed outcomes at baseline, midtreatment, treatment end, and 1 and 6 months post-treatment. Analyses were intent to treat.

Results

T-CBT outperformed TAU on all depression, anxiety, and quality of life measures. The primary outcome (Hamilton Depression Rating Scale score) improved significantly in T-CBT compared to TAU by treatment end. Mean improvement from baseline was 6.53 points for T-CBT and −0.27 points for TAU (p < 0.0001); gains persisted over 6-month follow-up (p < 0.0001). Improvements were moderated by a reduction in negative thoughts in the T-CBT group only, reflecting treatment target engagement.

Conclusions

T-CBT may be an effective depression intervention that addresses a significant unmet PD treatment need and bypasses access barriers to multidisciplinary, evidence-based care.

Clinicaltrials.gov identifier

NCT02505737.

Classification of evidence

This study provides Class I evidence that for patients with depression and PD, T-CBT significantly alleviated depressive symptoms compared to usual care.

Past-year opioid misuse and suicide attempt are positively associated in high suicide risk veterans who endorse past- year substance use

The main purpose of this study was to test the relationship between past-year suicide attempt (SA) and past-year opioid misuse among Veterans at high risk of suicide who reported using at least one illicit substance or alcohol in the past year. Baseline data from 130 high suicide-risk Veterans (n = 39 past-year opioid misusers; n = 91 past-year users of other substances) who enrolled in a randomized controlled trial testing adjunctive Mindfulness-Based Cognitive Therapy to Prevent Suicidal Behavior were used. Information was collected on a semi-structured interview that included the Columbia-Suicide Severity Rating Scale to collect suicide attempt history. Past-year opioid misusers, compared to those who used at least one other illicit substance or alcohol in the past year, were more likely to have made a past-year SA. Past-year opioid misuse remained associated with past-year SA in multivariate analysis that included other known risk factors for SA. Our findings show a robust link between near-term SA and opioid misuse in Veterans.

Cognitive behavioral therapy improves diverse profiles of depressive symptoms in Parkinson's disease

OBJECTIVE

Depression is among the most common and debilitating nonmotor complaints in Parkinson's disease (PD), yet there is a paucity of controlled research to guide treatment. Little research has focused on the extent to which specific depressive symptom profiles may dictate unique clinical recommendations to ultimately improve treatment outcomes. The current study examined the impact of cognitive behavioral therapy (CBT) on different types of depressive symptoms in PD. It was hypothesized that the cognitive (eg, guilt, rumination, and negative attitudes towards self) and behavioral (eg, avoidance and procrastination) symptoms targeted most intensively by the treatment protocol would show the most robust response. The extent to which stabilized antidepressant use moderated specific symptom change was examined on an exploratory basis.

METHOD

Eighty depressed people with PD participated in a randomized controlled trial of CBT plus clinical management, versus clinical management only. Hamilton Depression Rating Scale (HAMD) and Beck Depression Inventory (BDI) subscale scores, reflecting depressive symptom heterogeneity in PD, were the focus of this investigation.

RESULTS

CBT response was associated with significant improvements in mood, sleep, anxiety, and somatic symptoms (HAMD), and negative attitudes toward self, performance impairment, and somatic symptoms (BDI). As hypothesized, the largest effect sizes were observed for cognitive and behavioral (vs somatic) symptoms of depression. Stabilized antidepressant use moderated the effect of CBT on somatic complaints (HAMD and BDI).

CONCLUSIONS

CBT may improve a diverse array of depressive symptoms in PD. Cognitive and behavioral (vs somatic) symptoms showed the greatest change. Combining CBT with antidepressants may help optimize the management of somatic complaints in depression in PD (dPD).

Personalized Telemedicine for Depression in Parkinson's Disease: A Pilot Trial

High rates of depression are observed in Parkinson's disease, and limited access to care complicates management. The purpose of this pilot project was to evaluate the feasibility and impact of a personalized cognitive-behavioral telemedicine program for depression in Parkinson's disease (dPD). Thirty-four individuals with dPD and their carepartners participated in this pilot study. A 10-module self-help workbook, tailored to the unique needs of the dPD population, was created to be used as either a stand-alone intervention, with minimal therapist support, or a supplement to formal telephone-administered cognitive-behavioral therapy sessions. Improvements in depression, anxiety, quality of life, sleep, negative thoughts, and caregiver burden were observed over the course of the 4-month study, independent of treatment modality (guided self-help vs formal telephone-based psychotherapy). Future research will utilize randomized controlled designs and continue to focus on delivery models that can improve access to this and other evidence-based mental health interventions for dPD.

Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to Classify Suicidal Behaviors

Efforts to better understand and prevent suicide have increasingly pointed to the prospective assessment of suicidal behaviors in clinical trials. These assessments are aided by instruments such as the Columbia-Suicide Severity Rating Scale (C-SSRS), which have sought to improve the conceptual uniformity and ease by which suicidal behaviors are classified. At the same time, assessment and classification of suicidal behaviors has been a longtime challenge in the field. To aid users of the C-SSRS, this article illustrates the use of the C-SSRS in instances where classification complexities arise. Illustrations are presented based on cases encountered during a clinical trial for a suicide prevention intervention. Key decision points are summarized and classification issues that warrant consideration for future refinement of such decisions are discussed.

Patient-Provider Therapeutic Alliance Contributes to Patient Activation in Community Mental Health Clinics

Patient activation, often conceptualized as an individual trait, contributes to mental health outcomes. This study assessed the relational contributors to activation by estimating the longitudinal association of patient-provider communication and two factors of therapeutic alliance (agreement on tasks/goals and bond), with patient activation. Participants were patients (n = 264) from 13 community-based mental health clinics across the United States. In multivariate models, controlling for patients' individual and clinical characteristics, the task/goal factor of therapeutic alliance emerged as a significant and independent predictor of greater change in patient activation scores. Improving patient activation may require addressing patient-provider interactions such as coming to collaborative agreement on the tasks/goals of care.

Evaluating the Implementation of Home-Based Videoconferencing for Providing Mental Health Services

OBJECTIVE

The Veterans Health Administration (VHA) has recently implemented video-to-home (V2H) telehealth as part of a strategy to improve access to mental health treatment. Implementation research of this modality is needed, given that V2H telehealth transforms the traditional face-to-face delivery of mental health services. To address this need, V2H implementation was evaluated by examining barriers and facilitators that were associated with level of staff V2H experience and factors that differentiated facilities with various levels of V2H performance.

METHODS

Semistructured interviews with VHA personnel (N=33) from three facilities were conducted. The facilities were selected by overall number of mental health V2H visits during fiscal year (FY) 2015 as well as by growth in number of visits from FY 2014 through FY 2015. Factors influencing implementation were identified through qualitative analyses that contrasted responses by groups of participants with three different levels of V2H experience (no experience, limited experience, most experience) as well as three facilities that differed in V2H productivity (high visit count, high visit growth, and low visit count and low visit growth).

RESULTS

Providers seemed to encounter different barriers and facilitators depending on their level of experience with V2H. Site-level analyses illustrated the importance of logistical support, especially for providers who are newly adopting the technology. Other factors that differentiated the facilities were also identified and described.

CONCLUSIONS

Key factors related to implementation of V2H telehealth pertained to provider buy-in and logistical support. Facility-level strategies that address these factors may enhance provider progression from nonuse to sustained use.

Emotionally triggered asthma and its relationship to panic disorder, ataques de nervios, and asthma-related death of a loved one in Latino adults

OBJECTIVE

Research has demonstrated high comorbidity between asthma and panic disorder (PD). Less is known about the relationship between asthma and the Latino cultural idiom of distress of ataques de nervios, as well as the role that psychosocial stressors play. The current study tested the hypotheses that Latino asthma patients who experience PD, ataques de nervios, and/or asthma-related death of a loved one endorse greater psychological triggers of asthma, greater perceived impact of asthma triggers, and greater difficulty controlling such triggers than do those without these conditions.

METHODS

Data originated from an interview conducted prior to a randomized controlled trial in which 292 Latino adults with self-reported asthma were recruited from outpatient clinics in the Bronx, NY. The PRIME-MD Patient Health Questionnaire (PHQ) was used to screen for PD symptoms, while the Structured Clinical Interview for DSM-IV (SCID-I) was used to confirm diagnosis of PD. Lifetime history of ataques de nervios and asthma-related death of a loved one were based upon self-report. Asthma triggers were examined using the Asthma Trigger Inventory (ATI).

RESULTS

PD, ataques de nervios, and asthma-related death of a loved one each predicted a higher frequency of psychological asthma triggers, controlling for gender and comorbid medical conditions. Participants with PD also reported greater impact of asthma triggers than those without PD, while no significant differences in perceived control were observed.

CONCLUSION

Providers should screen for PD, ataques de nervios, and asthma-related death of a loved one in Latino asthma patients, given their observed association with emotionally triggered asthma.

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.

Randomized controlled trial of a brief Internet-based intervention for families of Veterans with posttraumatic stress disorder

Veterans with posttraumatic stress disorder (PTSD) and their families require resources to cope with postdeployment readjustment. Responding to this need, the current study examined a brief Internet-based intervention that provided Veterans' families with psychoeducation on postdeployment readjustment. Participants were 103 dyads of Veterans with probable PTSD and a designated family member/partner. Dyads were randomized to an intervention group, in which the family member completed the intervention, or to a control group with no intervention. Each member of the dyad completed surveys at baseline and 2 mo follow-up. Family member surveys focused on perceived empowerment, efficacy to provide support, and communication (perceived criticism and reactivity to criticism). Veteran surveys assessed perceived family support and communication. Results showed that Veterans in the intervention group reported decreases in reactivity to criticism but also decreased perceived family support. No significant differences were observed in outcomes reported by family members. This preliminary study provides an early understanding of this novel outreach program, as well as the challenges inherent with a very brief intervention. Future research can build on the current study by more closely evaluating the communication changes that occur with this form of intervention and whether greater intervention intensity is needed.

CLINICAL TRIAL REGISTRATION

Clinical Trials Identifier: NCT01554839.

Reviewing Mindfulness-Based Interventions for Suicidal Behavior

This article describes the rationale for using mindfulness-based interventions (MBIs) to prevent suicidal behavior in high suicide-risk individuals. A narrative review of studies testing the feasibility of MBIs with individuals at risk for suicidal behavior and the effectiveness of MBIs for reducing suicidality was conducted. Studies testing the effectiveness of MBIs for reducing deficits specific to suicide attempters among depressed individuals were also reviewed as were studies examining moderators of MBI treatment adherence and effectiveness to the extent that these might suggest possible limitations to using MBIs with high suicide-risk individuals. Findings from the handful of available studies support targeting suicidal ideation with MBI. Additional studies show deficits associated with suicide attempt, namely attentional dyscontrol, problem solving deficits, and abnormal stress response, are improved by MBI and thus strengthen the rationale for using MBIs with high suicide-risk individuals.

MORBID THOUGHTS AND SUICIDAL IDEATION IN IRAQ WAR VETERANS: THE ROLE OF DIRECT AND INDIRECT KILLING IN COMBAT

BACKGROUND

Although research has identified numerous risk factors for military suicide, the contribution of combat exposure to suicide risk has not been clearly established. Previous studies finding no association of suicidality with combat exposure have employed overgeneral measures of exposure, which do not differentiate among the varieties of combat experiences. This study disaggregated the forms of combat exposure to assess the contribution of combat-related killing to morbid thoughts and suicidal ideation (MTSI) in National Guard troops deployed to Iraq.

METHODS

We conducted parallel analyses of two related samples: a cross-sectional sample (n = 1,665) having postdeployment interview data only and a longitudinal subsample (n = 922) having pre- and postdeployment data. We used multiple logistic regression to examine the role of killing-related exposures, after controlling for general combat and other suicide risks, and examined interactions between killing and other suicide vulnerability factors.

RESULTS

Killing-related exposure approximately doubled the risk of MTSI in the cross-sectional multivariate model (Adjusted Odds Ratio [AOR] = 1.87; CI = 1.26-2.78) and the longitudinal model (AOR = 2.02; CI = 1.06-3.85), which also controlled for predeployment risks. Killing exposures further increased the MTSI risk associated with other suicide vulnerability factors, including depression (AOR = 14.89 for depression and killing vs. AOR = 9.92 for depression alone), alcohol dependence (AOR = 5.63 for alcohol and killing vs. 1.91 for alcohol alone), and readjustment stress (AOR = 4.90 for stress and killing vs. 1.48 for stress alone). General combat exposure had no comparable effects.

CONCLUSIONS

The findings underscore a need for assessment and treatment protocols that address the psychological effects of killing-related and other potentially "morally injurious" experiences among combat soldiers.

Activation, self-management, engagement, and retention in behavioral health care: a randomized clinical trial of the DECIDE intervention

IMPORTANCE

Given minority patients' unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care.

OBJECTIVE

To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care.

DESIGN, SETTING, AND PATIENTS

In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes.

INTERVENTIONS

Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health.

MAIN OUTCOMES AND MEASURES

Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records.

RESULTS

Patients assigned to DECIDE reported significant increases in activation (mean β = 1.74, SD = 0.58; P = .003) and self-management (mean β = 2.42, SD = 0.90; P = .008) relative to control patients, but there was no evidence of an effect on engagement or retention in care.

CONCLUSIONS AND RELEVANCE

The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01226329

Increased risk of alcohol dependency in a cohort of National Guard troops with PTSD: a longitudinal study

Studies show high rates of co-morbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) but there is no consensus on the causal direction of the relationship. Some theories suggest AUD develops as a coping mechanism to manage PTSD symptoms and others that AUD is a vulnerability factor for PTSD. A third hypothesis posits independent developmental pathways stemming from a shared etiology, such as the trauma exposure itself. We examined these hypotheses using longitudinal data on 922 National Guard soldiers, representing a subsample (56%) of a larger pre- and post-deployment cross-sectional study of New Jersey National Guard soldiers deployed to Iraq. Measures included the PTSD Checklist (PCL), DSM-IV-based measures of alcohol use/misuse from the National Household Survey of Drug Use and Health and other concurrent mental health, military and demographic measures. Results showed no effect of pre-deployment alcohol status on subsequent positive screens for new onset PTSD. However, in multivariate models, baseline PTSD symptoms significantly increased the risk of screening positive for new onset alcohol dependence (AD), which rose 5% with each unit increase in PCL score (AOR = 1.05; 95% CI = 1.02-1.07). Results also supported the shared etiology hypothesis, with the risk of a positive screen for AD increasing by 9% for every unit increase in combat exposure after controlling for baseline PTSD status (AOR = 1.09; 95% CI = 1.03-1.15) and, in a subsample with PCL scores <34, by 17% for each unit increase in exposure (AOR = 1.17; 95% CI = 1.05-1.31). These findings have implications for prevention, treatment and compensation policies governing co-morbidity in military veterans.

Multiple deployments and combat trauma: do homefront stressors increase the risk for posttraumatic stress symptoms?

Multiple deployments are common among military personnel who served in Operation Enduring Freedom and Operation Iraqi Freedom and are associated with greater posttraumatic stress symptoms (PTSS). Homefront stressors (i.e., family, occupational problems) resulting from deployments may increase the risk of PTSS. Moreover, with multiple deployments, a new deployment may occur while still experiencing homefront stressors from previous tours. This prospective study assessed whether homefront stressors from a previous tour increased the risk of PTSS after a new deployment. It also examined the effects of homefront stressors at postdeployment. Survey data were obtained from U.S. National Guard soldiers with previous deployments prior to (Wave 1) and after (Wave 2) a new deployment to Iraq (N = 196). Homefront stressors reported at Wave 1 (β = .154, p = .015) and Wave 2 (β = .214, p = .002) were both significantly predictive of PTSS at postdeployment, even after adjusting for warzone stressors, predeployment PTSS, and other variables. A pattern of chronic homefront stressors (i.e., homefront stressors at pre- and postdeployment) was associated with higher levels of PTSS at postdeployment (β = .220, p = .002). Service members with multiple deployments are at greater risk for PTSS if deployed with homefront stressors from previous tours and/or face these stressors at postdeployment.

A randomized-controlled trial of an intervention to improve antidepressant adherence among Latinos with depression

BACKGROUND

Studies have consistently shown that Latinos with depression have lower adherence to antidepressant medication. Given that low adherence is associated with poorer response to treatment, this is a likely source of unequal care. The current study examined the efficacy of a motivational interviewing intervention for improving antidepressant adherence among Latinos with a depressive disorder.

METHODS

Participants were 50 Latinos with a DSM-IV diagnosis of major depression or dysthymia who were receiving treatment at a community mental health center. Participants were recruited from July 2007 to December 2009 and were randomized to receive usual care (UC) or Motivational Enhancement Therapy for Antidepressants (META). META participants received three sessions of motivational interviewing as an enhancement to their usual care. Participants were assessed as baseline (time 1), 5 weeks (time 2), and 5 months (time 3). Antidepressant adherence was measured with the Medication Event Monitoring System (MEMS®) and changes in depression were measured with the Beck Depression Inventory-II (BDI-II).

RESULTS

After adjusting for covariates, META participants showed significantly higher antidepressant adherence than UC participants at time 2 (72% versus 42%, respectively, p < .01) and time 3 (60% versus 34%, p < .01). The groups did not differ on mean BDI-II score across time. However, after adjusting for covariates, META participants were significantly more likely to show symptom remission on the BDI-II, compared to UC participants (OR = 7.0, p < .05).

CONCLUSIONS

This initial trial of META demonstrated feasibility and promising effects for improving antidepressant adherence. Some effects on depression were also observed.

Transcultural aspects of somatic symptoms in the context of depressive disorders

Somatic symptoms are a common presentation of mental disorders or psychological distress worldwide, and may often coexist with depressive and anxiety symptoms, thus accounting for what might be the most frequent psychiatric syndrome in primary care. Indeed, physical symptoms accompanying the clinical presentations of a variety of mental disorders may be considered as universal 'idioms of distress' that may vary across cultures, depending on attitudes and explanations embedded in each one of them. These variations in symptom presentations are the result of various interacting factors that ultimately determine how individuals identify and classify bodily sensations, perceive illness, and seek medical attention. This chapter examines the impact of culture on the experiencing of somatic symptoms, based on an inclusive review of the topic from ethnic, nosological, clinical and social perspectives. Particular attention is paid to the association of somatic symptoms with mood symptoms, since depressive disorders appear to be the most common, costly and disabling psychiatric entities worldwide. The review shows that racial/ethnic variations in somatic symptoms in the context of depression are common, and seem to be related to depression severity. Sociocultural factors, particularly stigma, may influence the unique emphasis placed on somatic symptoms within depression, and may account for some racial/ethnic differences in somatic symptom reporting.

Improving treatment engagement of underserved U.S. racial-ethnic groups: a review of recent interventions

OBJECTIVE

Unequal mental health among U.S. underserved racial-ethnic populations has become a prominent national concern. Contributing to this inequity is our limited ability to engage individuals from underserved populations into treatment. To help address this, a systematic literature review was conducted to examine the evidence base for interventions that can improve mental health treatment engagement among underserved racial-ethnic minority populations.

METHODS

A MEDLINE search and bibliographic review yielded 1,611 studies that were reviewed according to several inclusion criteria: publication during or after 2001, U.S. adult sample, a randomized design, sufficient (≥50%) representation of underserved racial-ethnic groups, adequate sample size (≥27 participants per condition), explicit focus on mental health treatment engagement, and evaluation of an engagement outcome (for example, adherence or retention).

RESULTS

Ten studies met inclusion criteria. Evidence supported the efficacy of collaborative care for depression as an engagement enhancement intervention among underserved racial-ethnic populations. Several other interventions demonstrated possible efficacy. The effect of the interventions on clinical outcomes, such as symptom improvement and rehospitalization, was mixed.

CONCLUSIONS

Collaborative care for depression can be recommended for improving engagement in depression care in primary care among underserved racial-ethnic populations. Future research should continue to examine approaches with initial evidence of efficacy in order to expand the number of engagement enhancement interventions for underserved racial-ethnic adult populations. Additional issues for future engagement research include relative intervention efficacy across racial-ethnic groups, inclusion of other understudied groups (for example, Asian Americans and Native Americans), and greater clarification of the impact of improved engagement on clinical outcomes.

Gender differences in the risk and protective factors associated with PTSD: a prospective study of National Guard troops deployed to Iraq

This study examines gender differences in post-traumatic stress symptoms (PTSS) and PTSS risk/protective factors among soldiers deployed to Iraq. We pay special attention to two potentially modifiable military factors, military preparedness and unit cohesion, which may buffer the deleterious psychological effects of combat. Longitudinal data were collected on 922 New Jersey National Guard soldiers (91 women) deployed to Iraq in 2008. Anonymous surveys administered at pre- and post-deployment included the PTSD Checklist (PCL), the Unit Support Scale, and a preparedness scale adapted from the Iowa Gulf War Study. Bivariate analyses and hierarchical multiple regression were used to identify predictors of PTSS and their explanatory effects on the relationship between gender and PTSS. Women had a higher prevalence of probable post-deployment PTSD than men (18.7% vs. 8.7%; OR = 2.45; CI [1.37, 4.37]) and significantly higher post-deployment PTSS (33.73 vs. 27.37; p = .001). While there were no gender differences in combat exposure, women scored higher on pre-deployment PTSS (26.9 vs. 23.1; p ≤ .001) and lower on military preparedness (1.65 vs. 2.41; p ≤ .001) and unit cohesion (32.5 vs. 38.1; p ≤ .001). In a multivariate model, controlling for all PTSS risk/resilience factors reduced the gender difference as measured by the unstandardized Beta (B) by 45%, with 18% uniquely attributable to low cohesion and low preparedness. In the fully controlled model, gender remained a significant predictor of PTSS but the effect size was small (d = .26). Modifiable military institutional factors may account for much of the increased vulnerability of women soldiers to PTSD.

Readjustment stressors and early mental health treatment seeking by returning National Guard soldiers with PTSD

OBJECTIVES

Readjustment stressors are commonly encountered by veterans returning from combat operations and may help motivate treatment seeking for posttraumatic stress disorder (PTSD). The study examined rates of readjustment stressors (marital, family, and employment) and their relationship to early mental health treatment seeking among returning National Guard soldiers with PTSD.

METHODS

Participants were 157 soldiers who were surveyed approximately three months after returning from combat operations in Iraq and scored positive on the PTSD Checklist (PCL). The survey asked soldiers about their experience with nine readjustment stressors as well as their use of mental health care in the three months after returning.

RESULTS

Many readjustment stressors were common in this cohort, and most soldiers experienced at least one stressor (72%). Univariate analyses showed that readjustment stressors were related to higher rates of treatment seeking. These findings remained significant after multivariate analyses adjusted for depression and PTSD severity but were no longer significant after adjustment for age and marital status.

CONCLUSIONS

Readjustment stressors are common among soldiers returning from duty with PTSD and may be more predictive than PTSD symptom levels in treatment seeking. These effects appeared to be at least partially accounted for by demographic variables and the role of greater familial and occupational responsibilities among older veterans. Treatment seeking may be motivated by social encouragement or social interference and less by symptom severity.

Stigma and depression treatment utilization among Latinos: utility of four stigma measures

OBJECTIVES

Stigma associated with mental illness is an important yet understudied issue among Latinos. This study examined the psychometric properties of four stigma measures with a sample of Spanish-speaking Latino primary care patients. The study evaluated the scale for Perceived Discrimination Devaluation (PDD), the Stigma Concerns About Mental Health Care (SCMHC) scale, the Latino Scale for Antidepressant Stigma (LSAS), and the Social Distance (SD) scale.

METHODS

Participants (N=200) were low-income Latinos who were screened for depression with the Patient Health Questionnaire (PHQ-2) and asked about their depression treatment history, and they completed the four stigma measures at two time points (25 and 30 months from baseline). The four stigma measures were examined for internal consistency, convergent validity, construct validity, and criterion-related validity.

RESULTS

The factor-analytic results generally provided support for the construct validity of the measures. The four stigma measures also demonstrated internal consistency between two time points. Patients who reported greater social distance from individuals with depression were more likely to have been receiving treatment for emotional care in the past three months (odds ratio [OR]=.70, p<.05). Also, Latinos who scored high on the SCMHC (OR=.64, p<.05) and LSAS (OR=.77, p<.05) were less likely to have been taking antidepressant medications.

CONCLUSIONS

The SCMHC, LSAS, and SD scales received support for their reliability and construct validity. Results also showed some support for their criterion-related validity. A more mixed picture emerged for the PDD. Stigma ratings were associated with depression treatment utilization. Stigma ratings changed over time and were associated with treatment experiences.

Stigma and depression treatment utilization among Latinos: utility of four stigma measures

OBJECTIVES

Stigma associated with mental illness is an important yet understudied issue among Latinos. This study examined the psychometric properties of four stigma measures with a sample of Spanish-speaking Latino primary care patients. The study evaluated the scale for Perceived Discrimination Devaluation (PDD), the Stigma Concerns About Mental Health Care (SCMHC) scale, the Latino Scale for Antidepressant Stigma (LSAS), and the Social Distance (SD) scale.

METHODS

Participants (N=200) were low-income Latinos who were screened for depression with the Patient Health Questionnaire (PHQ-2) and asked about their depression treatment history, and they completed the four stigma measures at two time points (25 and 30 months from baseline). The four stigma measures were examined for internal consistency, convergent validity, construct validity, and criterion-related validity.

RESULTS

The factor-analytic results generally provided support for the construct validity of the measures. The four stigma measures also demonstrated internal consistency between two time points. Patients who reported greater social distance from individuals with depression were more likely to have been receiving treatment for emotional care in the past three months (odds ratio [OR]=.70, p<.05). Also, Latinos who scored high on the SCMHC (OR=.64, p<.05) and LSAS (OR=.77, p<.05) were less likely to have been taking antidepressant medications.

CONCLUSIONS

The SCMHC, LSAS, and SD scales received support for their reliability and construct validity. Results also showed some support for their criterion-related validity. A more mixed picture emerged for the PDD. Stigma ratings were associated with depression treatment utilization. Stigma ratings changed over time and were associated with treatment experiences.

Adaptation of a motivational interviewing intervention to improve antidepressant adherence among Latinos

Poor antidepressant adherence is a significant issue in depression treatment that adversely affects treatment outcomes. Although being a common problem, it tends to be more common among Latinos. To address this problem, the current study adapted a Motivational Interviewing (MI) intervention to improve adherence among Latinos with depression. The adaptation process included six focus groups that elicited participants' perspectives (N = 30), applying the intervention with test cases (N = 7) to fine-tune the intervention, and eliciting feedback on the intervention (N = 5). The findings generated from these adaptation phases are described, along with a case example. Examples of adaptations to the MI included reframing antidepressant adherence as a way to luchar (struggle) against problems, focusing on motivation for improving depression and not just medication, refining methods for imparting antidepressant information, and inclusion of personalized visual feedback on dose-taking. The findings provide a description of the antidepressant issues experienced by a group of Latinos, as well as considerations for applying MI with this population. The intervention remained grounded in MI principles, but was contextualized for this Latino group.

The use of a mentoring-based conference as a research career stimulation strategy

PURPOSE

U.S. minority populations, including Latinos, face disparities in many areas of health care: their risk for disease is higher, and their clinical outcomes and quality of care are worse. The discourse related to disparity often highlights the need to increase the number of minority scientists so that the productivity of research focusing on minority populations expands. To work toward this goal, a group of Latino mental health researchers collaborated to develop a national network of senior mentors who participate in annual mentoring-oriented conferences. The group developed a cost-effective program to stimulate the entry of new investigators into the field and to provide mentoring with a focus on Latino mental health issues.

METHOD

The authors describe a conference platform used as a career stimulation strategy. Five annual conferences (2002-2006) showcased new investigators' work, paired new investigators with senior researchers, and provided a feedback-oriented environment. The authors used quantitative data to track new investigator career progress (i.e., publications, research grants) and qualitative data to assess all attendees' feedback, which was provided via conference feedback questionnaires.

RESULTS

The feedback questionnaires revealed high levels of satisfaction with the conference, noting most highly the interactive, friendly, and nurturing conference format. Career tracking data indicated that nearly half of the new investigator participants published their work in peer-reviewed journals, and about one third were successful in obtaining research funding.

CONCLUSIONS

These mentoring conferences seem to be an effective tool for stimulating the research careers of new investigators engaged in Latino mental health research.

Lessons learned from the clinical reappraisal study of the Composite International Diagnostic Interview with Latinos

Given recent adaptations of the World Health Organization's World Mental Health Composite International Diagnostic Interview (WMH-CIDI), new methodological studies are needed to evaluate the concordance of CIDI diagnoses with clinical diagnostic interviews. This paper summarizes lessons learned from a clinical reappraisal study done with US Latinos. We compare CIDI diagnoses with independent clinical diagnosis using the World Mental Health Structured Clinical Interview for DSM-IV (WMH-SCID 2000). Three sub-samples stratified by diagnostic status (CIDI positive, CIDI negative, or CIDI sub-threshold for a disorder) based on nine disorders were randomly selected for a telephone re-interview using the SCID. We calculated sensitivity, specificity, and weight-adjusted Cohen's kappa. Weighted 12 month prevalence estimates of the SCID are slightly higher than those of the CIDI for generalized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence. For Latinos, CIDI-SCID concordance at the aggregate disorder level is comparable, albeit lower, to other published reports. The CIDI does very well identifying negative cases and classifying disorders at the aggregate level. Good concordance was also found for major depressive episode and panic disorder. Yet, our data suggests that the CIDI presents problems for assessing post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). Recommendations on how to improve future versions of the CIDI for Latinos are offered.

A qualitative analysis of the perception of stigma among Latinos receiving antidepressants

OBJECTIVE

This study sought to describe the role of stigma in antidepressant adherence among Latinos.

METHODS

The study utilized data generated from six focus groups of Latino outpatients receiving antidepressants (N=30). By using a grounded theory approach, qualitative analysis focused specifically on the role of stigma in antidepressant treatment, as well as salient Latino values.

RESULTS

Perceptions of stigma were related to both the diagnosis of depression and use of antidepressant medication. Qualitative analyses showed that antidepressant use was seen as implying more severe illness, weakness or failure to cope with problems, and being under the effects of a drug. Reports of stigma were also related to social consequences. Also, the perceived negative attributes of antidepressant use were at odds with self-perceived cultural values.

CONCLUSIONS

Stigma was a prominent concern among Latinos receiving antidepressants, and stigma often affected adherence. Furthermore, culture is likely to play an important role in the communication of stigma and its associated complications.

A qualitative analysis of the perception of stigma among Latinos receiving antidepressants

OBJECTIVE

This study sought to describe the role of stigma in antidepressant adherence among Latinos.

METHODS

The study utilized data generated from six focus groups of Latino outpatients receiving antidepressants (N=30). By using a grounded theory approach, qualitative analysis focused specifically on the role of stigma in antidepressant treatment, as well as salient Latino values.

RESULTS

Perceptions of stigma were related to both the diagnosis of depression and use of antidepressant medication. Qualitative analyses showed that antidepressant use was seen as implying more severe illness, weakness or failure to cope with problems, and being under the effects of a drug. Reports of stigma were also related to social consequences. Also, the perceived negative attributes of antidepressant use were at odds with self-perceived cultural values.

CONCLUSIONS

Stigma was a prominent concern among Latinos receiving antidepressants, and stigma often affected adherence. Furthermore, culture is likely to play an important role in the communication of stigma and its associated complications.

Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms

PURPOSE

Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients.

METHODS

We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care.

RESULTS

A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as "very much improved" or "much improved" compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9-8.8; P<.001). The intervention's effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up.

CONCLUSIONS

This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Somatic Complaints in Primary Care: Further Examining the Validity of the Patient Health Questionnaire (PHQ-15)

The authors examined the reliability and validity of the PHQ-15, a measure of current somatic complaints. An index of medically unexplained symptoms was used as a key criterion. Data were utilized from medical outpatients enrolled in a treatment study for moderate-to-severe somatization (N=172). Approximately 68% of the sample was Hispanic. Results showed that the PHQ-15 was moderately related to a history of medically unexplained symptoms among non-Hispanic participants. Results indicated ethnic differences on the validity profile of the PHQ-15 showing that the criterion variables were less predictive of the PHQ-15 among Hispanics than among non-Hispanics. Also, among the Hispanic group, the PHQ-15 was less related to medically unexplained symptoms and more to psychiatric distress. General support was provided for using the PHQ-15 with clinical samples composed of non-Hispanics. Also, the PHQ-15 appears to measure medically unexplained symptoms, psychiatric distress, and physical functioning. Further study is recommended to better evaluate ethnic variations and other types of validity for the PHQ-15.

Idiopathic physical symptoms: a common manifestation of psychiatric disorders in primary care

Worldwide, patients with common mental disorders, such as depression and anxiety, have a tendency to present first to primary care exhibiting idiopathic physical symptoms. Typically, these symptoms consist of pain and other physical complaints that remain medically unexplained. While in the past, traditional psychopathology emphasized the relevance of somatic presentations for disorders, such as depression, in the last few decades, the "somatic component" has been neglected in the assessment and treatment of psychiatric patients. Medical specialties have come up with a variety of "fashionable" labels to characterize these patients and the new psychiatric nomenclatures, such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, attempt to classify these patients into a separate "somatoform disorders" category. These efforts fall short, and revisionists are asking altogether for the elimination of "somatoform disorders" from future nomenclatures. This review emphasizes the importance of idiopathic physical symptoms to the clinical phenomenology of many psychiatric disorders, offers suggestions to the diagnostic conundrum, and provides some hints for the proper assessment and management of patients with these common syndromes.

The relationship between ataque de nervios and unexplained neurological symptoms: a preliminary analysis

Within somatization, unexplained neurological symptoms (UNSs) have been shown to mark a distinct subgroup with greater clinical severity. However, some UNSs resemble ataque de nervios somatic symptoms. This raises questions about cultural factors related to Hispanics with somatization characterized by UNSs. To examine cultural factors, preliminary analyses examined the relationship between Hispanic ethnicity, UNSs, and ataque de nervios. Data were obtained from 127 primary care patients (95 Hispanic, 32 European American) with somatization. The Composite International Diagnostic Interview provided somatization data, whereas the Primary Care Evaluation of Mental Disorders was used for data on Axis I disorders. Ataque de nervios was assessed via a proxy measure. Within each ethnic group, cross-tabs examined the relationship between ataque de nervios and multiple UNSs, and ataque de nervios and selected Axis I disorders. Only among Hispanics, a significant overlap was found between ataque de nervios and having four or more UNSs (p < .001), and ataque de nervios and a diagnosis of panic disorder (p = .05). Although equal percentages of European Americans and Hispanics experience multiple UNSs, these results show that the presentation of UNSs among some Hispanics may be qualitatively different, because it may involve features related to ataque de nervios. A diagnosis of panic disorder also appears to interact with cultural factors.

The value of pseudoneurological symptoms for assessing psychopathology in primary care

OBJECTIVE

This study sought to examine the relationship between pseudoneurological symptoms (PNS) and somatic and psychiatric symptom severity, physical functioning, and psychiatric comorbidity.

METHODS

Interview and questionnaire data were obtained from 120 patients with somatization who participated in a study assessing the efficacy of cognitive-behavioral therapy. Measures elicited information on psychiatric diagnoses, anxiety and depressive symptom levels, somatic symptoms, and physical functioning. Statistical analyses examined the relationship between PNS and the diagnosis of somatization disorder, physical and psychiatric symptom severity, and psychiatric comorbidity.

RESULTS

Roughly half of the sample had a history of four or more PNS. Results showed that having four or more PNS was not predictive of somatization disorder. However, having four or more PNS was found to be significantly correlated with the severity of anxiety, depression, somatic complaints, and physical dysfunction. These associations were identified while controlling for the symptom count of nonpseudoneurological symptoms, the presence of somatization disorder, and the presence of chronic painful physical conditions. In addition, having four or more PNS was significantly associated with a higher likelihood of receiving a diagnosis of major depression, dysthymia, panic disorder, and generalized anxiety disorder.

CONCLUSIONS

A history of four or more PNS is common among somatizing patients in primary care and associated with a more severe clinical presentation, even after controlling for other factors known to be associated with severity. Four or more PNS may identify a distinct subgroup of somatization and serve as a clinical indicator for identifying psychiatric disorders in primary care. Future studies should explore the assessment of PNS using briefer measures. Furthermore, PNS should be evaluated with samples more representative of US primary care populations, as well as samples that include adequate representation from other ethnic backgrounds (eg, African-American, Asian, etc.).