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Gupta T, Eckstrand KL, Forbes EE. Annual Research Review: Puberty and the development of anhedonia - considering childhood adversity and inflammation. J Child Psychol Psychiatry 2024; 65:459-480. [PMID: 38391011 PMCID: PMC10939801 DOI: 10.1111/jcpp.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Anhedonia, or diminished pleasure and motivation, is a symptom of severe mental illness (e.g., depressive disorder, bipolar disorder, schizophrenia) that emerges during adolescence. Anhedonia is a pernicious symptom that is related to social impairments, treatment resistance, and suicide. As the mechanisms of anhedonia are postulated to include the frontostriatal circuitry and the dopamine neuromodulatory system, the development and plasticity of these systems during the vulnerable period of adolescence, as well as their sensitivity to pubertal hormones, suggest that pubertal maturation could play a role in the development of anhedonia. This review takes a developmental perspective, considering the possibility that anhedonia emerges in the context of pubertal maturation and adolescent development, with childhood adversity and chronic inflammation influencing neural reward systems to accelerate anhedonia's progression. Here, we review the relevant extant literature on the components of this model and suggest directions for future research.
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Affiliation(s)
- Tina Gupta
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA USA
| | | | - Erika E. Forbes
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA USA
- University of Pittsburgh, Department of Psychology, Pittsburgh, PA USA
- University of Pittsburgh, Department of Pediatrics, Pittsburgh PA USA
- University of Pittsburgh, Department of Clinical and Translational Science, Pittsburgh PA USA
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Gupta T, Eckstrand KL, Lenniger CJ, Haas GL, Silk JS, Ryan ND, Phillips ML, Flores LE, Pizzagalli DA, Forbes EE. Anhedonia in adolescents at transdiagnostic familial risk for severe mental illness: Clustering by symptoms and mechanisms of association with behavior. J Affect Disord 2024; 347:249-261. [PMID: 37995926 PMCID: PMC10843785 DOI: 10.1016/j.jad.2023.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 11/07/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Anhedonia is a transdiagnostic symptom of severe mental illness (SMI) and emerges during adolescence. Possible subphenotypes and neural mechanisms of anhedonia in adolescents at risk for SMI are understudied. METHODS Adolescents at familial risk for SMI (N = 81) completed anhedonia (e.g., consummatory, anticipatory, social), demographic, and clinical measures and one year prior, a subsample (N = 46) completed fMRI scanning during a monetary reward task. Profiles were identified using k-means clustering of anhedonia type and differences in demographics, suicidal ideation, impulsivity, and emotional processes were examined. Moderation analyses were conducted to investigate whether levels of brain activation of reward regions moderated the relationships between anhedonia type and behaviors. RESULTS Two-clusters emerged: a high anhedonia profile (high-anhedonia), characterized by high levels of all types of anhedonia, (N = 32) and a low anhedonia profile (low-anhedonia), characterized by low levels of anhedonia types (N = 49). Adolescents in the high-anhedonia profile reported more suicidal ideation and negative affect, and less positive affect and desire for emotional closeness than low-anhedonia profile. Furthermore, more suicidal ideation, less positive affect, and less desire for emotional closeness differentiated the familial high-risk, high-anhedonia profile adolescents from the familial high-risk, low-anhedonia profile adolescents. Across anhedonia profiles, moderation analyses revealed that adolescents with high dmPFC neural activation in response to reward had positive relationships between social, anticipatory, and consummatory anhedonia and suicidal ideation. LIMITATIONS Small subsample with fMRI data. CONCLUSION Profiles of anhedonia emerge transdiagnostically and vary on clinical features. Anhedonia severity and activation in frontostriatal reward areas have value for clinically important outcomes such as suicidal ideation.
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Affiliation(s)
- T Gupta
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA.
| | - K L Eckstrand
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA
| | - C J Lenniger
- University of Pittsburgh, Department of Psychology, Pittsburgh, PA, USA
| | - G L Haas
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA; University of Pittsburgh, Department of Psychology, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - J S Silk
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA; University of Pittsburgh, Department of Psychology, Pittsburgh, PA, USA
| | - N D Ryan
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA
| | - M L Phillips
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA
| | - L E Flores
- Queens University, Department of Psychology, Kingston, Ontario, CA, USA
| | - D A Pizzagalli
- Harvard Medical School and McLean Hospital, Department of Psychiatry, Boston, MA, USA
| | - E E Forbes
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, USA; University of Pittsburgh, Department of Psychology, Pittsburgh, PA, USA; University of Pittsburgh, Department of Pediatrics, Pittsburgh, PA, USA; University of Pittsburgh, Department of Clinical and Translational Science, Pittsburgh, PA, USA
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Spigner ST, Rivera NV, Ufomata E, Mark EG, Grieve V, Faeder M, Fulmer VL, Van Deusen R, Gowl C, Hofkosh D, Eckstrand KL. Assessing Patient Goals for Gender-Affirming Hormone Therapy: A Standardized Patient Case for Medical Students. MedEdPORTAL 2023; 19:11356. [PMID: 38028957 PMCID: PMC10654112 DOI: 10.15766/mep_2374-8265.11356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 07/31/2023] [Indexed: 12/01/2023]
Abstract
Introduction Inadequate coverage of transgender and gender-diverse (TGD) health in the UME curriculum contributes to the scarcity of competent physicians to care for TGD patients. Increasing TGD health skills-based curricula in UME can help address TGD health disparities. We developed a standardized patient (SP) case to assess TGD health skills-based competencies and attitudes among medical students. Methods An interdisciplinary team, including individuals with lived TGD experience, developed the SP case that was completed by second-year medical students at the University of Pittsburgh School of Medicine in January 2020. After the TGD SP session, students and faculty completed a postsession survey to assess the degree to which the case met the learning objectives. Students were assessed via self-reports, faculty reports, and SP video evaluations. Results Seventy second-year medical students, 30 faculty facilitators, and eight SPs participated in 2020. Students reported being significantly more prepared to care for TGD patients (Z = -5.68, p < .001) and to obtain a gender history (Z = -5.82, p < .001). Both faculty and students felt that skills for caring for TGD patients were important in medical education and agreed the case should remain in the curriculum. Discussion The case effectively honed and assessed students' ability to collect a gender history and discuss goals for hormone therapy with TGD patients. It should complement ongoing curricula to effectively train medical students in TGD health care. Developing these skills in students directly addresses the barriers that many TGD patients experience in health care settings.
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Affiliation(s)
- Sabina T. Spigner
- Fourth-Year Medical Student, University of Pittsburgh School of Medicine
- Co-primary author
| | - Nicole V. Rivera
- Clinical Instructor, Department of Psychiatry, Warren Alpert Medical School at Brown University
- Co-primary author
| | - Eloho Ufomata
- Associate Professor, Department of Medicine, University of Pittsburgh School of Medicine
| | - Elyse G. Mark
- Third-Year Medical Student, University of Pittsburgh School of Medicine
| | - Victoria Grieve
- Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy
| | - Morgan Faeder
- Assistant Professor of Psychiatry and Neurology, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Valerie L. Fulmer
- Director, Standardized Patient Program, University of Pittsburgh School of Medicine
| | - Reed Van Deusen
- Associate Professor, Department of Medicine, University of Pittsburgh School of Medicine
| | - Catherine Gowl
- Standardized Patient Program Specialist, University of Pittsburgh School of Medicine
| | - Dena Hofkosh
- Emeritus Professor of Pediatrics, University of Pittsburgh School of Medicine
| | - Kristen L. Eckstrand
- Assistant Professor, Department of Psychiatry, University of Pittsburgh School of Medicine
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Call CC, Eckstrand KL, Kasparek SW, Boness CL, Blatt L, Jamal-Orozco N, Novacek DM, Foti D. An Ethics and Social-Justice Approach to Collecting and Using Demographic Data for Psychological Researchers. Perspect Psychol Sci 2023; 18:979-995. [PMID: 36459692 PMCID: PMC10235209 DOI: 10.1177/17456916221137350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The collection and use of demographic data in psychological sciences has the potential to aid in transforming inequities brought about by unjust social conditions toward equity. However, many current methods surrounding demographic data do not achieve this goal. Some methods function to reduce, but not eliminate, inequities, whereas others may perpetuate harmful stereotypes, invalidate minoritized identities, and exclude key groups from research participation or access to disseminated findings. In this article, we aim to (a) review key ethical and social-justice dilemmas inherent to working with demographic data in psychological research and (b) introduce a framework positioned in ethics and social justice to help psychologists and researchers in social-science fields make thoughtful decisions about the collection and use of demographic data. Although demographic data methods vary across subdisciplines and research topics, we assert that these core issues-and solutions-are relevant to all research within the psychological sciences, including basic and applied research. Our overarching aim is to support key stakeholders in psychology (e.g., researchers, funding agencies, journal editors, peer reviewers) in making ethical and socially-just decisions about the collection, analysis, reporting, interpretation, and dissemination of demographic data.
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Affiliation(s)
| | | | | | | | | | | | - Derek M. Novacek
- Department of Psychiatry and Biobehavioral Sciences, UCLA and Desert Pacific Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System
| | - Dan Foti
- Department of Psychological Sciences, Purdue University
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Liu Q, Nestor BA, Eckstrand KL, Cole DA. Stress proliferation in ethnoracial disparities of mental health among U.S. sexual minority adults. Cultur Divers Ethnic Minor Psychol 2023:2023-74917-001. [PMID: 37227853 DOI: 10.1037/cdp0000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Non-White sexual minorities experience disproportionate adverse childhood experiences (ACEs) and adulthood discrimination, as compared to their White or heterosexual counterparts. These stressors lead to increased psychological distress and worsened clinical outcomes, including suicidality. Minority stress theory posits that systemic marginalization, as experienced by minoritized individuals, leads to distress. Intersectionality theory suggests that marginalization compounds over time for individuals with intersectional minority identities. Yet, the mechanisms underlying the stress proliferation process for individuals with intersectional minority identities remain largely unexamined. METHOD The present study used nationally representative data of sexual minority individuals (n = 1,518, Mage = 31 years, ethnoracial minority = 38.7%, female and gender minority = 50.6%) to investigate the relations among ethnoracial minoritization, ACEs, discrimination, distress, and self-injurious/suicidal outcomes. We proposed a novel integration of minority stress, intersectionality, and stress proliferation theories. Via longitudinal mediation, we tested models of stress persistence, stress accumulation, and stress sensitization. RESULTS Our results confirmed disparities between White versus non-White sexual minorities on ACEs, discrimination experiences, and psychological distress. We found support for the stress persistence and the stress accumulation models, but not the stress sensitization model. Moreover, we found distress and discrimination were associated with future nonsuicidal self-injurious behaviors and suicidal outcomes, highlighting the deleterious consequences of intersectional minority stress proliferation. CONCLUSION Our results support our proposed theory of intersectional minority stress proliferation where ethnoracial and sexual minoritization intersect and beget disproportionate ACEs, which in turn contribute to accumulation and persistence of psychological distress and discrimination experiences in adulthood. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Qimin Liu
- Department of Psychology and Human Development, Vanderbilt University
| | - Bridget A Nestor
- Department of Psychology and Human Development, Vanderbilt University
| | | | - David A Cole
- Department of Psychology and Human Development, Vanderbilt University
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Green R, Eckstrand KL, Faeder M, Tilstra S, Ufomata E. Affirming Care for Transgender Patients. Med Clin North Am 2023; 107:371-384. [PMID: 36759103 DOI: 10.1016/j.mcna.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person's assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.
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Affiliation(s)
- Rebecca Green
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh School of Medicine, Loeffler Building #301, 121 Meyran Avenue, Pittsburgh, PA 15213, USA
| | - Morgan Faeder
- University of Pittsburgh School of Medicine, UPMC Psychiatry CL, 3600 Forbes Avenue, Suite 306, Pittsburgh, PA 15213, USA
| | - Sarah Tilstra
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Eloho Ufomata
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Eckstrand KL, Silk JS, Nance M, Wallace ML, Buckley N, Lindenmuth M, Flores L, Alarcón G, Quevedo K, Phillips ML, Lenniger CJ, Sammon MM, Brostowin A, Ryan N, Jones N, Forbes EE. Medial Prefrontal Cortex Activity to Reward Outcome Moderates the Association Between Victimization Due to Sexual Orientation and Depression in Youth. Biol Psychiatry Cogn Neurosci Neuroimaging 2022; 7:1289-1297. [PMID: 36064188 PMCID: PMC9842132 DOI: 10.1016/j.bpsc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sexual minority youth (SMY) are 3 times more likely to experience depression than heterosexual peers. Minority stress theory posits that this association is explained by sexual orientation victimization, which acts as a stressor to impact depression. For those vulnerable to the effects of stress, victimization may worsen depression by altering activity in neural reward systems. This study examines whether neural reward systems moderate the influence of sexual orientation victimization, a common and distressing experience in SMY, on depression. METHODS A total of 81 participants ages 15 to 22 years (41% SMY, 52% marginalized race) reported sexual orientation victimization, depression severity, and anhedonia severity, and underwent a monetary reward functional magnetic resonance imaging task. Significant activation to reward > neutral outcome (pfamilywise error < .05) was determined within a meta-analytically derived Neurosynth reward mask. A univariate linear model examined the impact of reward activation and identity on victimization-depression relationships. RESULTS SMY reported higher depression (p < .001), anhedonia (p = .03), and orientation victimization (p < .001) than heterosexual youth. The bilateral ventral striatum, medial prefrontal cortex (mPFC), anterior cingulate cortex, and right orbitofrontal cortex were significantly active to reward. mPFC activation moderated associations between sexual orientation victimization and depression (p = .03), with higher depression severity observed in those with a combination of higher mPFC activation and greater orientation victimization. CONCLUSIONS Sexual orientation victimization was related to depression but only in the context of higher mPFC activation, a pattern observed in depressed youth. These novel results provide evidence for neural reward sensitivity as a vulnerability factor for depression in SMY, suggesting mechanisms for disparities, and are a first step toward a clinical neuroscience understanding of minority stress in SMY.
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Affiliation(s)
| | - Jennifer S. Silk
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA
| | - Melissa Nance
- Department of Psychology, University of Missouri St. Louis, St. Louis, MO
| | | | - Nicole Buckley
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | | | - Luis Flores
- Department of Psychology, Queen’s University, Kingston, Ontario, Canada
| | - Gabriela Alarcón
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Karina Quevedo
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Mary L. Phillips
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | | | - M. McLean Sammon
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Alyssa Brostowin
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Neal Ryan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Neil Jones
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Erika E. Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA,Department of Psychology, University of Pittsburgh, Pittsburgh, PA
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Mains-Mason JB, Ufomata E, Peebles JK, Dhar CP, Sequeira G, Miller R, Folb B, Eckstrand KL. Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review. Acad Med 2022; 97:1847-1853. [PMID: 35703197 PMCID: PMC9837881 DOI: 10.1097/acm.0000000000004768] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD). METHOD The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020. RESULTS Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation. CONCLUSIONS Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.
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Affiliation(s)
- Janke B Mains-Mason
- J.B. Mains-Mason is a senior research associate, Department of Pathology, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Eloho Ufomata
- E. Ufomata is assistant professor, Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0002-2175-806X
| | - J Klint Peebles
- J.K. Peebles is a dermatologist, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Washington, DC
| | - Cherie P Dhar
- C.P. Dhar is assistant professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0003-1994-3722
| | - Gina Sequeira
- G. Sequeira is assistant professor, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; ORCID: http://orcid.org/0000-0001-5906-869X
| | - Rebekah Miller
- R. Miller is a research and instruction librarian, Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0002-9783-8234
| | - Barbara Folb
- B. Folb is a public health informationist, Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0001-5531-980X
| | - Kristen L Eckstrand
- K.L. Eckstrand is assistant professor, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0002-6506-3649
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Morgan JK, Eckstrand KL, Silk JS, Olino TM, Ladouceur CD, Forbes EE. Maternal Response to Positive Affect Moderates the Impact of Familial Risk for Depression on Ventral Striatal Response to Winning Reward in 6- to 8-Year-Old Children. Biol Psychiatry Cogn Neurosci Neuroimaging 2022; 7:824-832. [PMID: 35101605 PMCID: PMC9339024 DOI: 10.1016/j.bpsc.2021.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/08/2021] [Accepted: 12/31/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND A growing body of research has demonstrated that adolescent offspring of depressed parents show diminished responding in the ventral striatum to reward. More recent work has suggested that altered reward responding may emerge earlier than adolescence in offspring at familial risk for depression, although factors associated with neural alterations in childhood remain poorly understood. METHODS We tested whether 6- to 8-year-old children, 49% at heightened risk for depression via maternal history, showed altered neural responding to winning reward. We evaluated whether maternal socialization of positive emotion moderated the association between familial risk and child neural response to reward. Participants were 49 children 6 to 8 years of age (24 with a maternal history of recurrent or chronic depression, 25 with no maternal history of any psychiatric disorder). Children underwent functional magnetic resonance imaging while completing the Doors Guessing Task, a widely used reward guessing task. Mothers reported their use of encouraging and dampening responses to child positive affect. RESULTS Findings demonstrated that children at high familial risk for depression showed lower ventral striatum responding to winning reward relative to low-risk children, but only when mothers used less encouragement or greater dampening responses to their child's positive emotion expressions. CONCLUSIONS Neural reward alterations in the ventral striatum may emerge earlier than previously thought, as early as 6 to 8 years of age, specifically in the context of maternal discouragement of child positive emotions. Clinical interventions that focus on coaching mothers on how to encourage child positive emotions may be beneficial for supporting child reward-related brain development.
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Affiliation(s)
- Judith K Morgan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer S Silk
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas M Olino
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Cecile D Ladouceur
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
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10
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Flores LE, Alarcón G, Eckstrand KL, Lindenmuth M, Forbes EE. Interpersonal context and desired emotional closeness in neural response to negative visual stimuli: Preliminary findings. Brain Behav 2022; 12:e2438. [PMID: 34874622 PMCID: PMC8785641 DOI: 10.1002/brb3.2438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/08/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Emotions typically emerge in interpersonal contexts, but the neural circuitry involved remains insufficiently understood. Two key features of interpersonal contexts are interpersonal interactions (e.g., supportive physical touch serving as a form of social regulation) and interpersonal traits. Social regulation research has predominately focused on fear by using physical threat (i.e., electric shock) as the stimulus. Given that social regulation helps with various negative emotions in the real world, using visual stimuli that elicit negative emotions more broadly would also be beneficial. Differing from trait loneliness-which is related to lower recruitment of social circuitry in negative socioaffective contexts-trait desired emotional closeness is related to adaptive outcomes and may demonstrate an opposite pattern. This study investigated the roles of social regulation and desired emotional closeness in neural response to aversive social images. METHODS Ten pairs of typically developing emerging adult friends (N = 20; ages 18-25) completed a functional magnetic resonance imaging (fMRI) handholding task. Each friend viewed negative and neutral social images in the scanner under two conditions: (a) holding their friend's hand and (b) having their friend in the room. RESULTS Handholding attenuated response to aversive social images in a region implicated in emotion and inhibitory control (right dorsal striatum/anterior insula/ventrolateral prefrontal cortex). Desired emotional closeness was positively associated with response to aversive social images (in the no handholding condition) in self and social processing (right ventral posterior cingulate cortex) and somatosensory regions (right postcentral gyrus). DISCUSSION These findings extend previous research on the roles of interpersonal behaviors and tendencies in neural response to aversive stimuli.
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Affiliation(s)
- Luis E Flores
- Department of Psychology, Queen's University, Kingston, Canada
| | - Gabriela Alarcón
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Morgan Lindenmuth
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Thoma BC, Eckstrand KL, Montano GT, Rezeppa TL, Marshal MP. Gender Nonconformity and Minority Stress Among Lesbian, Gay, and Bisexual Individuals: A Meta-Analytic Review. Perspect Psychol Sci 2021; 16:1165-1183. [PMID: 33645322 PMCID: PMC7646043 DOI: 10.1177/1745691620968766] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Lesbian, gay, and bisexual (LGB) individuals are less healthy than heterosexual individuals, and minority stress endured by LGB individuals contributes to these health disparities. However, within-groups differences in minority stress experiences among LGB individuals remain underexplored. Individuals are more likely to be categorized as LGB if they exhibit gender nonconformity, so gender nonconformity could influence concealability of sexual orientation among LGB individuals, carrying important implications for the visibility of their stigmatized sexual orientation identity and for how they experience and cope with minority stress. Through a meta-analytic review, we examined how gender nonconformity was associated with minority stress experiences among LGB individuals. Thirty-seven eligible studies were identified and included in analyses. Results indicate gender nonconformity is associated with experiencing more prejudice events, less concealment of sexual orientation, lower internalized homonegativity, and higher expectations of rejection related to sexual orientation among LGB individuals. Gender nonconformity is more strongly associated with experiencing prejudice events among gay and bisexual men than among lesbian and bisexual women. Gender nonconformity is systematically associated with minority stress experiences among LGB individuals, and future research must measure and examine gender nonconformity when investigating the role of minority stress in degraded health outcomes among LGB populations.
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Affiliation(s)
| | | | - Gerald T Montano
- Department of Pediatrics, University of Pittsburgh School of Medicine
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Eckstrand KL, Forbes EE, Bertocci MA, Chase HW, Greenberg T, Lockovich J, Stiffler R, Aslam HA, Graur S, Bebko G, Phillips ML. Trauma Affects Prospective Relationships Between Reward-Related Ventral Striatal and Amygdala Activation and 1-Year Future Hypo/Mania Trajectories. Biol Psychiatry 2020; 89:868-877. [PMID: 33536131 PMCID: PMC8052260 DOI: 10.1016/j.biopsych.2020.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Trauma exposure is associated with a more severe, persistent course of affective and anxiety symptoms. Markers of reward neural circuitry function, specifically activation to reward prediction error (RPE), are impacted by trauma and predict the future course of affective symptoms. This study's purpose was to determine how lifetime trauma exposure influences relationships between reward neural circuitry function and the course of future affective and anxiety symptoms in a naturalistic, transdiagnostic observational context. METHODS A total of 59 young adults aged 18-25 (48 female and 11 male participants, mean ± SD = 21.5 ± 2.0 years) experiencing psychological distress completed the study. Participants were evaluated at baseline, 6, and 12 months. At baseline, the participants reported lifetime trauma events and completed a monetary reward functional magnetic resonance imaging task. Affective and anxiety symptoms were reported at each visit, and trajectories were calculated using MPlus. Neural activation during RPE and other phases of reward processing were determined using SPM8. Trauma and reward neural activation were entered as predictors of symptom trajectories. RESULTS Trauma exposure moderated prospective relationships between left ventral striatum (β = -1.29, p = .02) and right amygdala (β = 0.58, p = .04) activation to RPE and future hypo/mania severity trajectory: the interaction between greater trauma and greater left ventral striatum activation to RPE was associated with a shallower increase in hypo/mania severity, whereas the interaction between greater trauma and greater right amygdala activation to RPE was associated with increasing hypo/mania severity. CONCLUSIONS Trauma exposure affects prospective relationships between markers of reward circuitry function and affective symptom trajectories. Evaluating trauma exposure is thus crucial in naturalistic and treatment studies aiming to identify neural predictors of future affective symptom course.
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Affiliation(s)
- Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michele A Bertocci
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Henry W Chase
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tsafrir Greenberg
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeanette Lockovich
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ricki Stiffler
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Haris A Aslam
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Simona Graur
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Genna Bebko
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary L Phillips
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
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Ufomata E, Eckstrand KL, Spagnoletti C, Veet C, Walk TJ, Webb C, Gutiérrez EJ, Imming C, Guhl E, Jeong K, Rubio D, Hasley P. Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender. MedEdPORTAL 2020; 16:10875. [PMID: 32051853 PMCID: PMC7012308 DOI: 10.15766/mep_2374-8265.10875] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care. METHODS We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules. RESULTS Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable. DISCUSSION This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.
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Affiliation(s)
- Eloho Ufomata
- Assistant Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
- Corresponding author:
| | - Kristen L. Eckstrand
- Psychiatry Fellow, Department of Psychiatry, UPMC Western Psychiatric Institute and Clinic
| | - Carla Spagnoletti
- Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Clark Veet
- General Internal Medicine Fellow, Division of General Internal Medicine, University of Pittsburgh School of Medicine
- Clinical Instructor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Thomas J. Walk
- Clinical Instructor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
- Clinical Instructor of Medicine, Division of General Internal Medicine, VA Pittsburgh Healthcare System
| | - Camille Webb
- Clinical Instructor of Medicine, Division of Infectious Diseases, University of Texas Medical Branch School of Medicine
| | - Elena Jiménez Gutiérrez
- Assistant Professor, Division of General and Hospital Medicine, University of Texas Health Science Center at San Antonio School of Medicine
| | - Christina Imming
- Pediatric Hospitalist, UPMC Children's Hospital of Pittsburgh
- Primary Care Provider, Complex Care Center, UPMC Children's Hospital of Pittsburgh
| | - Emily Guhl
- Cardiology Fellow, University of Pittsburgh Medical Center
| | - Kwonho Jeong
- Statistician, Data Center, Center for Research on Health Care, University of Pittsburgh School of Medicine
| | - Doris Rubio
- Professor of Medicine, Biostatistics, Nursing, and Clinical and Translational Science, Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Peggy Hasley
- Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine
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Eckstrand KL, Flores LE, Cross M, Silk JS, Allen NB, Healey KL, Marshal MP, Forbes EE. Social and Non-social Reward Processing and Depressive Symptoms Among Sexual Minority Adolescents. Front Behav Neurosci 2019; 13:209. [PMID: 31572141 PMCID: PMC6753189 DOI: 10.3389/fnbeh.2019.00209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/29/2019] [Indexed: 12/01/2022] Open
Abstract
Sexual minority adolescents (SMA) are more likely to suffer from depression, putatively through experiences of social stress and victimization interfering with processing of social reward. Alterations in neural reward networks, which develop during adolescence, confer risk for the development of depression. Employing both social and monetary reward fMRI tasks, this is the first neuroimaging study to examine function in reward circuitry as a potential mechanism of mental health disparities between SMA and heterosexual adolescents. Eight SMA and 38 heterosexual typically developing adolescents completed self-report measures of depression and victimization, and underwent fMRI during monetary and peer social reward tasks in which they received positive monetary or social feedback, respectively. Compared with heterosexual adolescents, SMA had greater interpersonal depressive symptoms and exhibited blunted neural responses to social, but not monetary, reward in socioaffective processing regions that are associated with depressive symptoms. Specifically, compared with heterosexual adolescents, SMA exhibited decreased activation in the right medial prefrontal cortex, left anterior insula (AI), and right temporoparietal junction (TPJ) in response to being liked. Lower response in the right TPJ was associated with greater interpersonal depressive symptoms. These results suggest that interpersonal difficulties and the underlying substrates of response to social reward (perhaps more so than response to monetary reward) may confer risk for development of depressive symptoms in SMA.
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Affiliation(s)
- Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Luis E Flores
- Department of Psychology, Queen's University, Kingston, ON, Canada
| | - Marissa Cross
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jennifer S Silk
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nicholas B Allen
- Department of Psychology, University of Oregon, Eugene, OR, United States
| | - Kati L Healey
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States
| | - Michael P Marshal
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
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15
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Eckstrand KL, Forbes EE, Bertocci MA, Chase HW, Greenberg T, Lockovich J, Stiffler R, Aslam HA, Graur S, Bebko G, Phillips ML. Anhedonia Reduction and the Association Between Left Ventral Striatal Reward Response and 6-Month Improvement in Life Satisfaction Among Young Adults. JAMA Psychiatry 2019; 76:958-965. [PMID: 31066876 PMCID: PMC6506875 DOI: 10.1001/jamapsychiatry.2019.0864] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Anhedonia is a symptom of multiple psychiatric conditions in young adults that is associated with poorer mental health and psychosocial function and abnormal ventral striatum reward processing. Aberrant function of neural reward circuitry is well documented in anhedonia and other psychiatric disorders. Longitudinal studies to identify potential biomarkers associated with a reduction in anhedonia are necessary for the development of novel treatment targets. OBJECTIVE To identify neural reward-processing factors associated with improved psychiatric symptoms and psychosocial function in a naturalistic, observational context. DESIGN, SETTING, AND PARTICIPANTS A longitudinal cohort follow-up study was conducted from March 1, 2014, to June 5, 2018, at the University of Pittsburgh Medical Center after baseline functional magnetic resonance imaging in 52 participants between the ages of 18 and 25 years who were experiencing psychological distress. MAIN OUTCOMES AND MEASURES Participants were evaluated at baseline and 6 months. At baseline, participants underwent functional magnetic resonance imaging during a card-guessing monetary reward task. Participants completed measures of affective symptoms and psychosocial function at each visit. Neural activation during reward prediction error (RPE), a measure of reward learning, was determined using Statistical Parametric Mapping software. Neural reward regions with significant RPE activation were entered as regions associated with future symptoms in multiple linear regression models. RESULTS A total of 52 young adults (42 women and 10 men; mean [SD] age, 21.4 [2.2] years) completed the study. Greater RPE activation in the left ventral striatum was associated with a decrease in anhedonia symptoms during a 6-month period (β = -6.152; 95% CI, -11.870 to -0.433; P = .04). The decrease in anhedonia between baseline and 6 months mediated the association between left ventral striatum activation to RPE and improvement in life satisfaction between baseline and 6 months (total [c path] association: β = 0.245; P = .01; direct [c' path] association: β = 0.133; P = .16; and indirect [ab path] association: 95% CI, 0.026-0.262). Results were not associated with psychotropic medication use. CONCLUSIONS AND RELEVANCE Greater left ventral striatum responsiveness to RPE may serve as a biomarker or potential target for novel treatments to improve the severity of anhedonia, overall mental health, and psychosocial function.
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Affiliation(s)
| | - Erika E. Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michele A. Bertocci
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Henry W. Chase
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tsafrir Greenberg
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeanette Lockovich
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ricki Stiffler
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Haris A. Aslam
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Simona Graur
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Genna Bebko
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary L. Phillips
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
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16
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Coulter RWS, Egan JE, Kinsky S, Friedman MR, Eckstrand KL, Frankeberger J, Folb BL, Mair C, Markovic N, Silvestre A, Stall R, Miller E. Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review. Pediatrics 2019; 144:e20183367. [PMID: 31427462 PMCID: PMC6855817 DOI: 10.1542/peds.2018-3367] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions. OBJECTIVE To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY. DATA SOURCES PubMed, PsycINFO, and Education Resources Information Center. STUDY SELECTION Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY. DATA EXTRACTION Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor. RESULTS With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality. LIMITATIONS There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY. CONCLUSIONS The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.
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Affiliation(s)
- Robert W S Coulter
- Departments of Behavioral and Community Health Sciences and
- Center for LGBT Health Research, Graduate School of Public Health, and
- Department of Medicine, School of Medicine, and
- Department of Pediatrics, School of Medicine, University of Pittsburgh and Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - James E Egan
- Departments of Behavioral and Community Health Sciences and
- Center for LGBT Health Research, Graduate School of Public Health, and
| | - Suzanne Kinsky
- Departments of Behavioral and Community Health Sciences and
- Center for LGBT Health Research, Graduate School of Public Health, and
- Center for High-Value Health Care, UPMC, Pittsburgh, Pennsylvania; and
| | - M Reuel Friedman
- Center for LGBT Health Research, Graduate School of Public Health, and
- Infectious Diseases and Microbiology, and
| | | | | | - Barbara L Folb
- Departments of Behavioral and Community Health Sciences and
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christina Mair
- Departments of Behavioral and Community Health Sciences and
| | - Nina Markovic
- Center for LGBT Health Research, Graduate School of Public Health, and
- Department of Dental Public Health, School of Dental Medicine
| | - Anthony Silvestre
- Center for LGBT Health Research, Graduate School of Public Health, and
| | - Ron Stall
- Departments of Behavioral and Community Health Sciences and
- Center for LGBT Health Research, Graduate School of Public Health, and
| | - Elizabeth Miller
- Departments of Behavioral and Community Health Sciences and
- Department of Pediatrics, School of Medicine, University of Pittsburgh and Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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17
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Eckstrand KL, Hanford LC, Bertocci MA, Chase HW, Greenberg T, Lockovich J, Stiffler R, Aslam HA, Graur S, Bebko G, Forbes EE, Phillips ML. Trauma-associated anterior cingulate connectivity during reward learning predicts affective and anxiety states in young adults. Psychol Med 2019; 49:1831-1840. [PMID: 30229711 PMCID: PMC6684106 DOI: 10.1017/s0033291718002520] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma exposure is associated with development of depression and anxiety; yet, some individuals are resilient to these trauma-associated effects. Differentiating mechanisms underlying development of negative affect and resilience following trauma is critical for developing effective interventions. One pathway through which trauma could exert its effects on negative affect is reward-learning networks. In this study, we examined relationships among lifetime trauma, reward-learning network function, and emotional states in young adults. METHODS One hundred eleven young adults self-reported trauma and emotional states and underwent functional magnetic resonance imaging during a monetary reward task. Trauma-associated neural activation and functional connectivity were analyzed during reward prediction error (RPE). Relationships between trauma-associated neural functioning and affective and anxiety symptoms were examined. RESULTS Number of traumatic events was associated with greater ventral anterior cingulate cortex (vACC) activation, and lower vACC connectivity with the right insula, frontopolar, inferior parietal, and temporoparietal regions, during RPE. Lower trauma-associated vACC connectivity with frontoparietal regions implicated in regulatory and decision-making processes was associated with heightened affective and anxiety symptoms; lower vACC connectivity with insular regions implicated in interoception was associated with lower affective and anxiety symptoms. CONCLUSIONS In a young adult sample, two pathways linked the impact of trauma on reward-learning networks with higher v. lower negative affective and anxiety symptoms. The disconnection between vACC and regions implicated in decision-making and self-referential processes may reflect aberrant regulatory but appropriate self-focused mechanisms, respectively, conferring risk for v. resilience against negative affective and anxiety symptoms.
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Affiliation(s)
| | - Lindsay C Hanford
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | | | - Henry W Chase
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Tsafrir Greenberg
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | | | - Ricki Stiffler
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Haris A Aslam
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Simona Graur
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Genna Bebko
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Erika E Forbes
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
| | - Mary L Phillips
- Department of Psychiatry,University of Pittsburgh,Pittsburgh, PA,USA
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18
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Ambrosia M, Eckstrand KL, Morgan JK, Allen NB, Jones NP, Sheeber L, Silk JS, Forbes EE. Temptations of friends: adolescents' neural and behavioral responses to best friends predict risky behavior. Soc Cogn Affect Neurosci 2018; 13:483-491. [PMID: 29846717 PMCID: PMC6007330 DOI: 10.1093/scan/nsy028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 04/04/2018] [Indexed: 11/18/2022] Open
Abstract
Adolescents are notorious for engaging in risky, reward-motivated behavior, and this behavior occurs most often in response to social reward, typically in the form of peer contexts involving intense positive affect. A combination of greater neural and behavioral sensitivity to peer positive affect may characterize adolescents who are especially likely to engage in risky behaviors. To test this hypothesis, we examined 50 adolescents’ reciprocal positive affect and neural response to a personally relevant, ecologically valid pleasant stimulus: positive affect expressed by their best friend during a conversation about past and future rewarding mutual experiences. Participants were typically developing community adolescents (age 14–18 years, 48.6% female), and risky behavior was defined as a factor including domains such as substance use, sexual behavior and suicidality. Adolescents who engaged in more real-life risk-taking behavior exhibited either a combination of high reciprocal positive affect behavior and high response in the left ventrolateral prefrontal cortex—a region associated with impulsive sensation-seeking—or the opposite combination. Behavioral and neural sensitivity to peer influence could combine to contribute to pathways from peer influence to risky behavior, with implications for healthy development.
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Affiliation(s)
- Marigrace Ambrosia
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Judith K Morgan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Neil P Jones
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Jennifer S Silk
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Psychology
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Psychology.,Department of Pediatrics.,Center for the Neural Bases of Cognition, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Ufomata E, Eckstrand KL, Hasley P, Jeong K, Rubio D, Spagnoletti C. Comprehensive Internal Medicine Residency Curriculum on Primary Care of Patients Who Identify as LGBT. LGBT Health 2018; 5:375-380. [PMID: 30141734 DOI: 10.1089/lgbt.2017.0173] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Graduate medical education curricula that provide training on LGBT healthcare are limited. The purpose of this study was to create and evaluate an LGBT curriculum for internal medicine (IM) residents. METHODS The implicit association test (IAT) measuring implicit bias toward gay individuals was administered as part of a needs assessment. The curriculum was developed by a multidisciplinary team, with objectives derived from the Association of American Medical Colleges' curricular recommendations and the Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Surveys assessed residents' perceptions of the importance of primary care for LGBT patients, and their knowledge of and confidence in providing primary care to LGBT patients. Faculty also rated the usability of the curricular materials. RESULTS The IAT showed a slight preference for straight people compared with gay people, with an average "D score" of 0.27 ± 0.42. The importance of receiving education about the primary care of LGB patients was rated as high across the pre- to postsurveys. Knowledge improved with participation in the curriculum (average overall score: 42% pre- vs. 66% postsurvey, p < 0.0001). Participants' confidence in their ability to provide information to LGBT patients about resources for community engagement and to implement gender-neutral practices in their clinics increased significantly (p < 0.05). CONCLUSION This curriculum pilot demonstrated an improvement in IM residents' knowledge of and confidence in providing care to LGBT patients. Our results suggest that curricular materials can be developed by experts in LGBT health and utilized effectively by nonexpert faculty to increase residents' knowledge and confidence regarding LGBT healthcare.
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Affiliation(s)
- Eloho Ufomata
- 1 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Kristen L Eckstrand
- 2 Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Peggy Hasley
- 1 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Kwonho Jeong
- 3 Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Doris Rubio
- 1 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,3 Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Carla Spagnoletti
- 1 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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20
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Donald CA, Eckstrand KL. In Reply to Zaidi. Acad Med 2018; 93:10. [PMID: 29278590 DOI: 10.1097/acm.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Cameron A Donald
- Second-year medical student, School of Medicine, University of California, San Francisco, San Francisco, California; ; ORCID: http://orcid.org/0000-0001-8942-6443. Founding chair, Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Association of American Medical Colleges, Washington, DC, and third-year psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0002-6506-3649
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21
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Eckstrand KL, Mummareddy N, Kang H, Cowan R, Zhou M, Zald D, Silver HJ, Niswender KD, Avison MJ. An insulin resistance associated neural correlate of impulsivity in type 2 diabetes mellitus. PLoS One 2017; 12:e0189113. [PMID: 29228027 PMCID: PMC5724830 DOI: 10.1371/journal.pone.0189113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 11/20/2017] [Indexed: 02/06/2023] Open
Abstract
Central insulin resistance (IR) influences striatal dopamine (DA) tone, an important determinant of behavioral self-regulation. We hypothesized that an association exists between the degree of peripheral IR and impulse control, mediated by the impact of IR on brain circuits controlling the speed of executing “go” and/or “stop” responses. We measured brain activation and associated performance on a stop signal task (SST) in obese adults with type 2 diabetes (age, 48.1 ± 6.9 yrs (mean ± SD); BMI, 36.5 ± 4.0 kg/m2; HOMA-IR, 7.2 ± 4.1; 12 male, 18 female). Increasing IR, but not BMI, was a predictor of shorter critical stop signal delay (cSSD), a measure of the time window during which a go response can be successfully countermanded (R2 = 0.12). This decline was explained by an IR-associated increase in go speed (R2 = 0.13) with little impact of IR or BMI on stop speed. Greater striatal fMRI activation contrast in stop error (SE) compared with stop success (SS) trials (CONSE>SS) was a significant predictor of faster go speeds (R2 = 0.33, p = 0.002), and was itself predicted by greater IR (CONSE>SS vs HOMA-IR: R2 = 0.10, p = 0.04). Furthermore, this impact of IR on striatal activation was a significant mediator of the faster go speeds and greater impulsivity observed with greater IR. These findings suggest a neural mechanism by which IR may increase impulsivity and degrade behavioral self-regulation.
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Affiliation(s)
- Kristen L. Eckstrand
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Nishit Mummareddy
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ronald Cowan
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Minchun Zhou
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - David Zald
- Department of Psychology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Heidi J. Silver
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Kevin D. Niswender
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Malcolm J. Avison
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
- * E-mail:
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Eckstrand KL, Choukas-Bradley S, Mohanty A, Cross M, Allen NB, Silk JS, Jones NP, Forbes EE. Heightened activity in social reward networks is associated with adolescents' risky sexual behaviors. Dev Cogn Neurosci 2017; 27:1-9. [PMID: 28755632 PMCID: PMC5901964 DOI: 10.1016/j.dcn.2017.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/11/2017] [Accepted: 07/11/2017] [Indexed: 01/25/2023] Open
Abstract
Adolescent sexual risk behavior can lead to serious health consequences, yet few investigations have addressed its neurodevelopmental mechanisms. Social neurocircuitry is postulated to underlie the development of risky sexual behavior, and response to social reward may be especially relevant. Typically developing adolescents (N=47; 18M, 29F; 16.3±1.4years; 42.5% sexual intercourse experience) completed a social reward fMRI task and reported their sexual risk behaviors (e.g., lifetime sexual partners) on the Youth Risk Behavior Survey (YRBS). Neural response and functional connectivity to social reward were compared for adolescents with higher- and lower-risk sexual behavior. Adolescents with higher-risk sexual behaviors demonstrated increased activation in the right precuneus and the right temporoparietal junction during receipt of social reward. Adolescents with higher-risk sexual behaviors also demonstrated greater functional connectivity between the precuneus and the temporoparietal junction bilaterally, dorsal medial prefrontal cortex, and left anterior insula/ventrolateral prefrontal cortex. The greater activation and functional connectivity in self-referential, social reward, and affective processing regions among higher sexual risk adolescents underscores the importance of social influence underlying sexual risk behaviors. Furthermore, results suggest an orientation towards and sensitivity to social rewards among youth engaging in higher-risk sexual behavior, perhaps as a consequence of or vulnerability to such behavior.
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Affiliation(s)
- Kristen L Eckstrand
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Arpita Mohanty
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Marissa Cross
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nicholas B Allen
- Department of Psychology, University of Oregon, Eugene, OR, United States
| | - Jennifer S Silk
- Departments of Psychology and Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Neil P Jones
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Erika E Forbes
- Departments of Psychiatry, Psychology, and Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States.
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23
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Eckstrand KL, Lunn MR, Yehia BR. Applying Organizational Change to Promote Lesbian, Gay, Bisexual, and Transgender Inclusion and Reduce Health Disparities. LGBT Health 2017; 4:174-180. [DOI: 10.1089/lgbt.2015.0148] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristen L. Eckstrand
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mitchell R. Lunn
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
In 2014, the Association of American Medical Colleges (AAMC) published a report proposing qualifiers of competence to guide medical educators towards training physicians to appropriately care for individuals who are or may be lesbian, gay, bisexual, transgender (LGBT); gender nonconforming (GNC); and/or born with differences in sex development (DSD). These qualifiers provide content and context to an existing framework heavily used in competency-based medical education, emphasizing individual and interpersonal abilities to enhance care delivered to individuals identifying as LGBT, GNC, and/or born with DSD. However, systemic and societal forces including health insurance, implicit bias, and legal protections significantly impact the health of these communities. The concept of structural competency proposes that it is necessary to consider these larger forces contributing to and sustaining disease and health in order to fully address identity-based health needs. Competing competency frameworks for addressing diversity may be counterproductive to the ultimate goal of improving health outcomes among diverse communities. In this article, frameworks are reconciled by proposing structural competency as one approach for teaching identity-based health-related competencies that can be feasibly implemented for medical educators seeking to comply with the AAMC's recommendations. This article aims to "queer"-or to open up-possibilities in medical education in an effort to ultimately support the provision of equitable and responsible health care to people who are LGBT, GNC, and/or born with DSD through the use of innovative frameworks and teaching materials.
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Affiliation(s)
- Cameron A Donald
- C. Donald is a first-year medical student, University of California, San Francisco, School of Medicine, San Francisco, California.S. DasGupta is a faculty member, Graduate Program in Narrative Medicine, Center for the Study of Ethnicity and Race, and Institute for Comparative Literature and Society, Columbia University, New York, New York.J.M. Metzl is Frederick B. Rentschler II Professor of Sociology and Psychiatry and director, Center for Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee.K.L. Eckstrand is founding chair, Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Association of American Medical Colleges, Washington, DC, and a second-year psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Bayer CR, Eckstrand KL, Knudson G, Koehler J, Leibowitz S, Tsai P, Feldman JL. Sexual Health Competencies for Undergraduate Medical Education in North America. J Sex Med 2017; 14:535-540. [PMID: 28202322 DOI: 10.1016/j.jsxm.2017.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/08/2017] [Accepted: 01/24/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The number of hours spent teaching sexual health content and skills in medical education continues to decrease despite the increase in sexual health issues faced by patients across the lifespan. In 2012 and 2014, experts across sexuality disciplines convened for the Summits on Medical School Education and Sexual Health to strategize and recommend approaches to improve sexual health education in medical education systems and practice settings. One of the summit recommendations was to develop sexual health competencies that could be implemented in undergraduate medical education curricula. AIM To discuss the process of developing sexual health competencies for undergraduate medical education in North America and present the resulting competencies. METHODS From 2014 to 2016, a summit multidisciplinary subcommittee met through face-to-face, phone conference, and email meetings to review prior competency-based guidelines and then draft and vet general sexual health competencies for integration into undergraduate medical school curricula. The process built off the Association of American Medical Colleges' competency development process for training medical students to care for lesbian, gay, bisexual, transgender, and gender non-conforming patients and individuals born with differences of sex development. MAIN OUTCOME MEASURES This report presents the final 20 sexual health competencies and 34 qualifiers aligned with the 8 overall domains of competence. RESULTS Development of a comprehensive set of sexual health competencies is a necessary first step in standardizing learning expectations for medical students upon completion of undergraduate training. CONCLUSIONS It is hoped that these competencies will guide the development of sexual health curricula and assessment tools that can be shared across medical schools to ensure that all medical school graduates will be adequately trained and comfortable addressing the different sexual health concerns presented by patients across the lifespan. Bayer CR, Eckstrand KL, Knudson G, et al. Sexual Health Competencies for Undergraduate Medical Education in North America. J Sex Med 2017;14:535-540.
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Affiliation(s)
- Carey Roth Bayer
- Departments of Community Health and Preventive Medicine/Medical Education; Center of Excellence for Sexual Health, Satcher Health Leadership Institute; Morehouse School of Medicine, Atlanta, GA, USA.
| | - Kristen L Eckstrand
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gail Knudson
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Jean Koehler
- Department of Psychiatry and Behavioral Sciences (Emerita), University of Louisville Medical School, Louisville, KY, USA
| | - Scott Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Perry Tsai
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jamie L Feldman
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA
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26
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Eckstrand KL, Travis MJ, Forbes EE, Phillips ML. Sex Differences and Personalized Psychiatric Care. Biol Psychiatry 2016; 80:e81-e83. [PMID: 27765159 PMCID: PMC5371428 DOI: 10.1016/j.biopsych.2016.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 09/14/2016] [Accepted: 09/14/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Kristen L Eckstrand
- Department of Psychiatry, Western Psychiatric Institute & Clinic of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael John Travis
- Department of Psychiatry, Western Psychiatric Institute & Clinic of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Erika E Forbes
- Department of Psychiatry, Western Psychiatric Institute & Clinic of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Louise Phillips
- Department of Psychiatry, Western Psychiatric Institute & Clinic of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abstract
Although recent changes in health care delivery have improved routine and gender-affirming care for transgender people, common approaches to care are still often based on a binary (i.e., male/female) gender framework that can make patients with gender-nonconforming (GNC) identities and expressions feel marginalized. Binary representation perpetuates invisibility, discrimination, and victimization-and subsequent poorer health-among GNC patients. In response, clinicians and health care systems should extend their efforts to provide gender-affirming and responsible care to GNC people. This article reviews terminology related to gender, the limited research-and necessary directions for future research-on GNC communities, and provides strategies for health care professionals and systems to ensure provision of gender-affirming and responsible care to GNC patients.
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Affiliation(s)
- Kristen L Eckstrand
- Psychiatry resident at the University of Pittsburgh Medical Center and the founding chair of the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development
| | - Henry Ng
- Associate professor of medicine and pediatrics and the assistant dean for admissions at Case Western Reserve University School of Medicine in Cleveland, Ohio, where he is also clinical director of the PRIDE Clinic at MetroHealth Medical Center
| | - Jennifer Potter
- Associate professor of medicine at Harvard Medical School in Boston, where she is also director of women's health research at the Fenway Institute
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Eckstrand KL, Potter J, Bayer CR, Englander R. Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations. Acad Med 2016; 91:930-5. [PMID: 26796092 PMCID: PMC4925271 DOI: 10.1097/acm.0000000000001088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee's process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.
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Affiliation(s)
- Kristen L Eckstrand
- K.L. Eckstrand is a psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and founding chair, Association of American Medical Colleges, Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Washington, DC. J. Potter is associate professor of medicine, Harvard Medical School, Cambridge, Massachusetts, and director, Women's Health Research, Fenway Institute, Boston, Massachusetts. C.R. Bayer is associate professor, Morehouse School of Medicine, and associate director of educational leadership, Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia. R. Englander was senior director of competency-based learning and assessment, Association of American Medical Colleges, and is currently adjunct professor of pediatrics, George Washington School of Medicine, Washington, DC
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29
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Abstract
Recent societal events highlight inequities experienced by underrepresented and marginalized communities. These inequities are the impetus for ongoing efforts in academic medicine to create inclusive educational and patient care environments for diverse stakeholders. Frequently, approaches focus on singular populations or broad macroscopic concepts and do not always elucidate the complexities that arise at the intersection between multiple identities and life experiences. Intersectionality acknowledges multidimensional aspects of identity inclusive of historical, structural, and cultural factors. Understanding how multiple identity experiences impact different individuals, from patients to trainees to providers, is critical for improving health care education and delivery. Building on existing work within academic medicine, this Commentary outlines six key recommendations to advance intersectionality in academic medicine: embrace personal and collective loci of responsibility; examine and rectify unbalanced power dynamics; celebrate visibility and intersectional innovation; engage all stakeholders in the process of change; select and analyze meaningful metrics; and sustain the commitment to achieving health equity over time. Members of the academic medical community committed to advancing health equity can use these recommendations to promote and maintain meaningful changes that recognize and respond to the multidimensional voices and expressed needs of all individuals engaged in providing and receiving health care.
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Affiliation(s)
- Kristen L Eckstrand
- K.L. Eckstrand is a psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and founding chair, Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Washington, DC. J. Eliason is lead research analyst, Diversity Policy and Programs, Association of American Medical Colleges, Washington, DC. T. St.Cloud is director of educational initiatives, Diversity Policy and Programs, Association of American Medical Colleges, Washington, DC. J. Potter is associate professor of medicine, Harvard Medical School, and director of women's health research, Fenway Institute, Boston, Massachusetts
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30
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Affiliation(s)
- Sean D. Chester
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jesse M. Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristen L. Eckstrand
- Vanderbilt Program for LGBTI Health, Vanderbilt University School of Medicine Nashville, Tennessee
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31
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Eckstrand KL, Ding Z, Dodge NC, Cowan RL, Jacobson JL, Jacobson SW, Avison MJ. Persistent dose-dependent changes in brain structure in young adults with low-to-moderate alcohol exposure in utero. Alcohol Clin Exp Res 2012; 36:1892-902. [PMID: 22594302 DOI: 10.1111/j.1530-0277.2012.01819.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Many children with heavy exposure to alcohol in utero display characteristic alterations in brain size and structure. However, the long-term effects of low-to-moderate alcohol exposure on these outcomes are unknown. METHODS Using voxel-based morphometry and region-of-interest analyses, we examined the influence of lower doses of alcohol on gray and white matter composition in a prospectively recruited, homogeneous, well-characterized cohort of alcohol-exposed (n = 11, age 19.5 ± 0.3 years) and control (n = 9, age 19.6 ± 0.5 years) young adults. A large proportion of the exposed individuals were born to mothers whose alcohol consumption during pregnancy was in the low-to-moderate range. RESULTS There were no differences in total brain volume or total gray or white matter volume between the exposed and control groups. However, gray matter volume was reduced in alcohol-exposed individuals in several areas previously reported to be affected by high levels of exposure, including the left cingulate gyrus, bilateral middle frontal gyri, right middle temporal gyrus, and right caudate nucleus. Notably, this gray matter loss was dose dependent, with higher exposure producing more substantial losses. CONCLUSIONS These results indicate that even at low doses, alcohol exposure during pregnancy impacts brain development and that these effects persist into young adulthood.
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Affiliation(s)
- Kristen L Eckstrand
- Department of Radiology and Radiological Sciences , Vanderbilt University Medical Center, Nashville, TN, USA
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