Threats to social safety and neuro-inflammatory mechanisms underlying sexual orientation disparities in depression symptom severity: A prospective cohort study of young adults

Sexual minority individuals have a markedly elevated risk of depression compared to heterosexuals. We examined early threats to social safety and chronically elevated inflammation as mechanisms contributing to this disparity in depression symptoms, and compared the relative strength of the co-occurrence between chronic inflammation and depression symptoms for sexual minorities versus heterosexuals. To do so, we analyzed data from a prospective cohort of sexual minority and heterosexual young adults (n = 595), recruited from a nationally representative sample, that included assessments of early threats to social safety in the form of adverse childhood interpersonal events, three biomarkers of inflammation (i.e., CRP, IL-6, TNF-α) measured at two time points, and depression symptoms over four years. In pre-registered analyses, we found that sexual minorities experienced more adverse childhood interpersonal events, were more likely to display chronically elevated inflammation, and reported more severe depression symptoms than heterosexuals. Adverse childhood interpersonal events and chronically elevated inflammation explained approximately 23 % of the total effect of the association between sexual orientation and depression symptom severity. Further, there was an increased coupling of chronically elevated inflammation and depression symptoms among sexual minorities compared to heterosexuals. These results provide novel longitudinal, population-based evidence for the role of chronically elevated inflammation in linking threats to social safety during childhood with depression symptom severity in young adulthood, consistent with the primary tenets of the social signal transduction theory of depression. Our study extends this theory to the population level by finding that members of a stigmatized population (i.e., sexual minorities) experience a greater risk of depression because of their greater exposure to adverse childhood interpersonal events and the subsequent link to chronic inflammation, highlighting potential biopsychosocial intervention targets.

Structural transphobia is associated with psychological distress and suicidality in a large national sample of transgender adults

PURPOSE

Transgender adults face increasingly discriminatory laws/policies and prejudicial attitudes in many regions of the United States (US), yet research has neither quantified state-level transphobia using indicators of both, nor considered their collective association with transgender adults' psychological wellbeing, hindering the identification of this potential social determinant of transgender mental health inequity.

METHODS

We therefore used factor analysis to develop a more comprehensive structural transphobia measure encompassing 29 indicators of transphobic laws/policies and attitudes at the state level, which we linked to individual-level mental health data from a large national sample of 27,279 transgender adults (ages 18-100) residing in 45 US states and the District of Columbia (DC).

RESULTS

Controlling for individual- (i.e., demographics), interpersonal- (i.e., perceived discrimination), and state- (i.e., income inequality, religiosity) level covariates, transgender adults from US states with higher (vs. lower) levels of structural transphobia reported more severe past-month psychological distress and were more likely to endorse past-year and lifetime suicidal thoughts, plans, and attempts.

CONCLUSION

Findings provide novel evidence that state-level transphobic laws/policies and attitudes collectively shape a range of important mental health outcomes among transgender adults in the US. Multilevel intervention strategies, such as affirming mental health treatments, provider-training interventions, and supportive legislation, are needed to address structural transphobia's multifaceted nature and negative mental health consequences.

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): study protocol for a randomized controlled effectiveness trial in outpatient clinics

BACKGROUND

Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST-a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change-regulation of negative emotions; and (3) explore variables that may influence clinicians' treatment implementation.

METHODS

This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7-15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.

DISCUSSION

This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.

TRIAL REGISTRATION

NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT04725721.

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): Study Protocol for a Randomized Controlled Effectiveness Trial in Outpatient Clinics

Background

Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST-a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change-regulation of negative emotions; and (3) explore variables that may influence clinicians' treatment implementation.

Methods

This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7-15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.

Discussion

This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.

Trial registration

NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT04725721.

Incorporating macro-social contexts into emotion research: Longitudinal associations between structural stigma and emotion processes among gay and bisexual men

Research into correlates and predictors of emotion regulation has focused almost exclusively on individual differences and the immediate situation. Here, we consider whether features of macro-social contexts may also shape emotion regulation. To test this hypothesis, we conducted a longitudinal study of 502 gay and bisexual men living in 269 U.S. counties that varied in the level of stigma surrounding sexual minorities. We find that gay and bisexual men living in higher- (vs. lower-) stigma counties consistently reported more suppression, which consequently explained longitudinal increases (vs. decreases) in their lack of emotional clarity over 24 months. Results were robust to demographic characteristics, stigma at the interpersonal level (i.e., sexual orientation-related discrimination), and another form of social inequality (i.e., county-level income inequality). These findings suggest that broadening the lens of emotion regulation research to include characteristics of the macro-social environment may yield new insights into determinants of emotion regulation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Transgender-Specific Adolescent Mental Health Provider Availability is Substantially Lower in States with More Restrictive Policies

OBJECTIVE

Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states - especially at the macro-social level - have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states' transgender-specific policy climate.

METHOD

We quantified states' policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states' transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers - identified via Psychology Today - per transgender adolescent in all 50 states and the District of Columbia.

RESULTS

Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio = 0.65, 95% CI [0.52, 0.81], p = .00017), controlling for state-level conservatism, religiosity, and urbanicity. States' transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity.

CONCLUSIONS

Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

Meta-analysis: Are Psychotherapies Less Effective for Black Youth in Communities With Higher Levels of Anti-Black Racism?

OBJECTIVE

To examine whether anti-Black cultural racism moderates the efficacy of psychotherapy interventions among youth.

METHOD

A subset of studies from a previous meta-analysis of 5 decades of youth psychotherapy randomized controlled trials was analyzed. Studies were published in English between 1963 and 2017 and identified through a systematic search. The 194 studies (N = 14,081 participants; age range, 2-19) across 34 states comprised 2,678 effect sizes (ESs) measuring mental health problems (eg, depression) targeted by interventions. Anti-Black cultural racism was operationalized using a composite index of 31 items measuring explicit racial attitudes (obtained from publicly available sources, eg, General Social Survey) aggregated to the state level and linked to the meta-analytic database. Analyses were conducted with samples of majority-Black (ie, ≥50% Black) (n = 36 studies) and majority-White (n = 158 studies) youth.

RESULTS

Two-level random-effects meta-regression analyses indicated that higher anti-Black cultural racism was associated with lower ESs for studies with majority-Black youth (β = -0.2, 95% CI [-0.35, -0.04], p = .02) but was unrelated to ESs for studies with majority-White youth (β = 0.0004, 95% CI [-0.03, 0.03], p = .98), controlling for relevant area-level covariates. In studies with majority-Black youth, mean ESs were significantly lower in states with the highest anti-Black cultural racism (>1 SD above the mean; Hedges' g = 0.19) compared with states with the lowest racism (<1 SD below the mean; Hedges' g = 0.60).

CONCLUSION

Psychotherapies tested with samples of majority-Black youth were significantly less effective in states with higher (vs lower) levels of anti-Black cultural racism, suggesting that anti-Black cultural racism may be one contextual moderator of treatment effect heterogeneity.

The effectiveness and acceptability of empirically supported treatments in gender minority youth across four randomized controlled trials

OBJECTIVE

Gender minority youth (i.e., children/adolescents whose gender identity and/or expression is inconsistent with their birth-assigned sex) experience elevated rates of emotional and behavioral problems relative to cisgender youth (who identify with their birth-assigned sex), which are not intrinsic to gender identity but attributable to unique minority stressors. Although empirically supported treatments have proven effective in treating these mental health concerns generally, randomized controlled trials have not examined effects for gender minority youth.

METHOD

To address this gap, we pooled data from clinically referred youth (N = 432; M(SD)age = 10.6(2.2); 55.1% White) assigned to empirically supported treatment conditions across four previous randomized controlled trials of modular psychotherapy. A proxy indicator of gender identity (i.e., youth's wish to be the opposite sex) was used to classify gender minority (n = 64) and cisgender (n = 368) youth. Youth- and caregiver-reported pretreatment internalizing and externalizing problems, treatment effectiveness on these domains, and treatment acceptability were compared across groups.

RESULTS

Gender minority youth reported more severe pretreatment internalizing and externalizing problems compared to cisgender youth; in contrast, their caregivers reported less severe problems. Although treatment was equally effective for both groups on most outcomes, gender minority youth's caregiver-reported externalizing problems improved more slowly and less reliably, and their self-reported internalizing problems were more likely to remain clinically elevated. Furthermore, gender minority youth reported lower treatment satisfaction.

CONCLUSIONS

While findings suggest that empirically supported treatments may effectively address many mental health problems for gender minority youth, they also underscore the need for treatment enhancements that improve acceptability and outcomes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).