How will identifying biomarkers for depression improve patients' lives?

How will identifying biomarkers for depression improve patients' lives?

The quest within scientific research to identify new biomarkers for a wide spectrum of diseases and disorders is something that we at Medical News Today report on frequently.

In recent months we have looked at studies investigating biomarkers that can be used to test concussion severity, the relationship between Alzheimer's biomarkers and severity of symptoms, and biomarkers as a fast, non-invasive test for brain cancer.

But can biomarkers be used to diagnose or improve treatment for patients with psychiatric disorders?

Mental health problems are often perceived as being "ethereal" in origin, compared with more visible and quantifiable health problems.

Depression, for instance, is not considered to have a specific root cause but is believed to be influenced by a combination of stressful life events, genetic susceptibility, chemical changes in the brain or other underlying medical conditions.

Yet, in the past couple of years, there has been a drive in research to locate biomarkers for depression and to develop reliable tests that detect these biomarkers in depressed patients.

Only last week, it was announced that the world's biggest scanning project - UK Biobank - is currently analyzing the DNA of half a million participants in order to identify biomarkers for conditions including not just the likes of cancer, stroke and heart disease, but also depression.

Biomarkers are "biological clues" that doctors can look for in patients to confirm the presence or risk of disease. These clues are usually found in changes in blood, urine or body tissue. Fasting glucose, for example, can be used to diagnose diabetes, and the presence of liver enzymes in the blood can indicate liver disease.

Biomarkers are a popular area of study. A 2012 article in Massachusetts General Hospital's Proto magazine calculated that out of 150,000 published papers announcing the discovery of thousands of new biomarkers for a range of conditions, only about 100 biomarkers are in routine use.

The article added that even some of the most long-established of these - such as prostate-specific antigen screening for prostate cancer and the antigen-125 blood test for ovarian cancer - have recently been discredited.

Finding new ways to identify the presence of disease is desirable where there is a demand for faster, cheaper and less invasive testing - such as in cancer and other severe conditions. But the hunt for new biomarkers is sometimes described as circular.

Given that the process of establishing biomarkers for any condition is prone to yielding disappointments, why is there an impetus to locate biomarkers for depression? Especially given that this is a condition that does not involve costly or invasive testing to diagnose?

Medical News Today put this question to Eva E. Redei, PhD, of the Feinburg School of Medicine at Northwestern University, IL. In 2012, Dr. Redei's research into blood biomarkers for major depressive disorder (MDD) in teenagers aged 15-19 was listed by The New York Times as one of "32 innovations that will change your tomorrow." Despite this, her work faced criticism. "The current level of hype for this study is unwarranted," insisted one colleague.

"I believe that the only way to convince those who do not believe in the accuracy or usefulness of biomarkers is to show their accuracy and process the diagnostic test through [the Food and Drug Administration]," Dr. Redei told us.

"The need is another issue," she says. "Primary care physicians see a large proportion of depressed patients. According to studies involving large number of patients, they diagnose correctly less than half of them."

Early and correct diagnosis, Dr. Redei reminds, leads to better treatment response, which "helps to reduce the burden of depression on the patients, their family and the society as a whole. Blood-based simple laboratory tests could help tremendously."

Dr. Redei's team identified a set of 11 genes that express proteins in the blood of teenagers with MDD, and a total of 26 biomarkers that they believed could differentiate between depressed teens, non-depressed teens and even teens with an anxiety disorder or other subtype of depression.

Blood-based simple laboratory tests could help remove depression's burden on patients, their families and society, Dr. Redei claims.

Currently, MDD is diagnosed by patients reporting their own symptoms, but Dr. Redei believes that her blood test would be more objective and have less bias than current diagnostic methods.

It could also provide comfort to adolescent patients who otherwise might not feel their condition is taken seriously by peers or family.

Not everyone was convinced, however. "From a public health point of view, you have to think, 'What value does this test have, and compared to what?,'" questioned Dr. Lloyd Sederer, medical director of the New York State Office of Mental Health.

"Standard clinical diagnosis is pretty good," Sederer wrote in The Huffington Post. "If you have essentially a low-tech, low-cost and relatively effective means of determining a condition, then all of those attributes have to be exceeded for something else to be more valuable.

"When something like this comes out and gets a lot of attention, it's a false promise to parents," he says of Redei's work. "And does it really shape, in any way, how effective your treatment is going to be now?"

Perhaps, though, there has been a shift in how tests for depression biomarkers are viewed - even within the 2 years since Dr. Redei's research was published in the journal Translational Psychiatry.

A recent study by researchers from Cambridge University in the UK, which proposed measuring levels of the stress hormone cortisol in adolescents' saliva as a diagnostic and prognostic marker for depression - alongside the traditional self-reported symptoms - seemed to generate more favorable commentary.

For example, Cynthia Joyce, chief executive of the charity MQ: Transforming Health, wrote in a blog for the Wellcome Trust:

"This finding is important because while any number of candidate biomarkers (genes, proteins, physical traits, symptoms) have been identified for depression, the associations have proven difficult to pin down and validate as bona fide markers.

This proof-of-concept study represents a real advance for the study of depression. The combined 'bio-behavioural' marker will enable more comprehensive study of how depression evolves over time, and perhaps even how we might prevent it."

The Cambridge study found that teenage boys who have a combination of depression symptoms and elevated cortisol are up to 14 times more likely to develop clinical depression than boys with no symptoms and stable cortisol levels.

The researchers behind the study - which was published in the Proceedings of the National Academy of Sciences - think that their test will allow health care providers to strategically target preventions and interventions at patients, reducing their risk of serious depression in adult life.

However, the cortisol test is only effective in males because women naturally have higher levels of cortisol. The team has not yet found an equivalent indicator for predicting outcomes in females.

MQ believe that this combination of physiological biomarkers and self-reported symptoms as a tool to predict clinical depression has powerful implications. In the wake of the study's publication, the charity announced a funding call inviting biological and psychological scientists to work together for advancing care and understanding of depression.

Whereas the Redei study supplemented diagnosis of depression in teenagers, and the Cambridge study claimed to predict later depression, other studies into biomarkers of depression have focused instead on personalizing treatment for depression.

One study, funded in 2013 by the National Institute of Mental Health (NIMH) and published in JAMA Psychiatry, used a positron emission tomography (PET) scanner to analyze which brain regions are active at any given moment in patients with depression.

The researchers compared the brain activity of patients who successfully entered remission following treatment with those who did not. The treatments considered in the study were the talking therapy cognitive behavioral therapy (CBT) and the serotonin specific reuptake inhibitor (SSRI) antidepressant escitalopram.

They found that low activity in the insula of the brain before treatment predicted that the patient would respond well to CBT as a treatment, but that they would be less likely to achieve remission through use of escitalopram. Conversely, hyperactivity in the insula would predict remission through escitalopram but a poor response to CBT.

Trial and error currently determines whether a patient best responds to talking therapies or antidepressants, and the NIMH reports that only about 40% of patients achieve remission after initial treatment for depression.

"This is costly in terms of human suffering as well as health care spending," the organization claims, suggesting that the PET scan approach could be useful in guiding doctors toward more effective initial treatment decisions.

Watch the video below for more details on this study:

Study lead Dr. Helen S. Mayberg told Medical News Today that the next step is to further explore patients at different stages of the illness and to explore "mechanistically distinct" types of antidepressants. She says that this will allow the team to develop treatment selection algorithms for all scenarios throughout the progression of the illness.

We asked Dr. Mayberg how urgent the need is to identify biomarkers for depression, given that some critics have suggested it is a fallible and over-hyped science.

Pointing out that physicians do a variety of tests to determine the best course of action for illnesses such as cancer - including tests to exclude specific treatments - she responded:

"To expect that with a disorder as complex as depression we should use a single measure of any type (blood, questionnaire, brain scan) to distinguish among patients that require psychotherapy or medication, or are likely to be treatment-resistant and go on to need [electroconvulsive therapy] or more invasive interventions, would be to ignore many years of research demonstrating that understanding the biological heterogeneity of the disorder is key - as with any other medical illness."

Other recent studies have also looked at using cytokines or C-reactive protein to predict patients' SSRI response.

"All of these studies are very important and useful in their separate ways," Dr. Redei told Medical News Today. "They employ accumulated knowledge about the biology of depression and use the markers that were studied previously to identify differences in expression of RNA, proteins of steroids (and other means) between patients and controls."

"Our study was a discovery-based one," she clarifies, whereas "the transcripts that are on the potential diagnostic marker panel are novel. Some of them are completely unknown. Because of that, they may also open novel areas of research."

Asked which test she considers to have the greatest evidence base and most promising clinical applications, she replied: "Of course I believe in ours the most!"

The search for depression biomarkers is not an isolated fad, some scientists claim, but is part of a much larger rethink happening throughout science right now on the physiological causes of depression.

The search for depression biomarkers is part of a rethink on the physiological causes of depression.

This innovative thinking is opening up potential new treatments for depression that go beyond the standard antidepressant function of increasing or blocking the neurotransmitters implicated in depression.

Now molecular biomarkers, such as monoamine and neurogenesis regulators, and mediators of glutaminergic and GABAergic activity, are being investigated for their role in depression, as is the atrophy of nerve cells in the hippocampus as a result of chronic stress.

A recent study of depression biomarkers by researchers from Loyola University Health System in Illinois listed corticotropin-releasing hormone antagonists, ketamine, partial adrenalectomy, benzodiazepines, anesthetics, deep brain stimulation and transcranial magnetic stimulation as new or forthcoming depression treatments.

The new theories behind the development of these depression therapies "should not be viewed as separate entities because they are highly interconnected," the authors write. "Integrating them provides for a more expansive understanding of the pathophysiology of depression and biomarkers that are involved."

Explaining that it can take months to recover from depression, the researchers suggest that existing depression treatment programs averaging 6 weeks are not long enough for adequate recovery. They hope the new biomarker-led research will not only enhance treatment, but open doors for a new understanding of depression. 

Many mental illnesses reduce life expectancy more than heavy smoking

Many mental illnesses reduce life expectancy more than heavy smoking

Serious mental illnesses reduce life expectancy by 10-20 years, an analysis by Oxford University psychiatrists has shown - a loss of years that's equivalent to or worse than that for heavy smoking.

Yet mental health has not seen the same public health priority, say the Oxford scientists, despite these stark figures and the similar prevalence of mental health problems.

1 in 4 people in the UK will experience some kind of mental health problem in the course of a year, it is estimated. Around 21% of British men and 19% of women smoke cigarettes.

The researchers say the figures should galvanise governments and health and social services to put a much higher priority on how mental health services can prevent early deaths.

The Oxford University researchers report their findings in the journal World Psychiatry. The study was funded by the Wellcome Trust.

The researchers searched for the best systematic reviews of clinical studies which reported mortality risk for a whole range of diagnoses - mental health problems, substance and alcohol abuse, dementia, autistic spectrum disorders, learning disability and childhood behavioural disorders. 20 review papers were identified, including over 1.7 million individuals and over 250,000 deaths.

They repeated searches for studies and reviews reporting life expectancy and risk of dying by suicide, and compared the results to the best data for heavy smoking.

The average reduction in life expectancy in people with bipolar disorder is between 9 and 20 years, it's 10-20 years for schizophrenia, between 9 and 24 years for drug and alcohol abuse, and around 7-11 years for recurrent depression.

The loss of years among heavy smokers is 8-10 years.

All diagnoses studied showed an increase in mortality risk, though the size of the risk varied greatly. Many had risks equivalent to or higher than heavy smoking (see table in notes for editors). Dr Seena Fazel of the Department of Psychiatry at Oxford University said: 'We found that many mental health diagnoses are associated with a drop in life expectancy as great as that associated with smoking 20 or more cigarettes a day.

'There are likely to be many reasons for this. High-risk behaviours are common in psychiatric patients, especially drug and alcohol abuse, and they are more likely to die by suicide. The stigma surrounding mental health may mean people aren't treated as well for physical health problems when they do see a doctor.'

One problem is the tendency to separate mental and physical illness, explains Dr Fazel. 'Many causes of mental health problems also have physical consequences and mental illness worsen the prognosis of a range of physical illnesses, especially heart disease, diabetes and cancer. Unfortunately, people with serious mental illnesses may not access healthcare effectively,' says Dr Fazel.

Dr Fazel is certain: 'All of this can be changed. There are effective drug and psychological treatments for mental health problems. We can improve mental health and social care provision. That means making sure people have straightforward access to health care, and appropriate jobs and meaningful daytime activities. It'll be challenging, but it can be done.'

He notes: 'Beyond that, psychiatrists have a particular responsibility as doctors to ensure that the physical health of their patients is not neglected. De-medicalization of psychiatric services mitigates against that.'

He adds: 'What we do need is for researchers, care providers and governments to make mental health a much higher priority for research and innovation. Smoking is recognised as a huge public health problem. There are effective ways to target smoking, and with political will and funding, rates of smoking-related deaths have started to decline. We now need a similar effort in mental health.'

Table of all-cause mortality for various mental health and other diagnoses as compared to general population and the mortality risk for heavy smoking. This summarises the best available evidence from reviews of research studies:

Risk of mortality compared with general populationRisk normalised to that for heavy smokingAcute and transient psychotic disorderIntellectual disability (moderate to profound)Eating disorder (not otherwise specified)* Mid-point of range; ** Mean value of male and female mortality

A research study carried out by Oxford University and funded by the Wellcome Trust has found that serious mental illnesses reduce life expectancy by 10-20 years, a loss of years equivalent or worse than that for heavy smoking. The meta-analysis, published tomorrow (Friday, 23 May) in the journal World Psychiatry, highlights the discrepancy between physical and mental health services. Geoff Heyes, Policy and Campaigns Manager at Mind, said:

"This new research adds to the significant body of evidence that people with mental health problems die younger than the general population. We know it is possible to live a long and healthy life with a mental health problem but under-funded and poorly integrated services are preventing people accessing a range of quality treatments to enable them to manage their both their physical and mental health.

"Campaigns such as Time to Change have helped reduce the stigma surrounding mental health problems, and people are becoming more willing to seek help sooner. However, when people with mental health problems do seek help, they can find it more difficult to access physical health services and have worse outcomes for physical health conditions, sometimes because health professionals write off their concerns about legitimate physical complaints as a symptom of their mental health condition.

"While smoking-cessation has been a public health priority and smoking related deaths have reduced in recent years, too little attention has been paid to evidence-based and targeted interventions to help people with mental health problems stop smoking. After all, 42% of all cigarettes smoked in England are by people with mental health problems.

"We urgently need to see mental health services given as much importance as physical health, and much better integration of mental and physical health services, so that people are treated as a whole and taken seriously."

Risks of all-cause and suicide mortality in mental disorders: a meta-review, Chesney, Goodwin and Fazel, World Psychiatry, published online Friday 23 May 2014.

Oxford University and Mind

Maternity leave often cut short by women who experienced unintended pregnancies

Maternity leave often cut short by women who experienced unintended pregnancies

According to a study led by Dr. Rada K. Dagher, assistant professor of health services administration at the University of Maryland School of Public Health, mothers in the United States who have unintended pregnancies return to work sooner after childbirth than mothers whose pregnancy was intended.

This is the first study to examine pregnancy intention and return to work after childbirth. "We know that it's better for women to take time off after childbirth to take care of their physical and mental health," says Dr. Dagher, whose previous research showed that taking six months of maternity leave is optimal for reducing a woman's risk of postpartum depression. "Returning to work soon after childbirth may not be good for these women or for their children." The study is published in Women's Health Issues, a leading journal in women's healthcare and policy.

To reduce unintended pregnancies, Dagher supports policies to ensure that a woman has access to appropriate methods for delaying pregnancy until she is ready to have a baby. "The Affordable Care Act requirement for health plans to cover contraceptives at no cost to the consumer is an important part of the strategy to reduce unintended pregnancies," Dr. Dagher said. She also recommends that health care providers counsel all women and men who are at risk for unintended pregnancy about the most effective contraceptive methods.

The study findings also point to the need for policies that enable women to take longer maternity leaves. "Compared to mothers with an intended pregnancy, mothers with an unintended pregnancy are not as emotionally and financially prepared and are less likely to receive paid maternity leave, suggesting that economic reasons may have forced them to return to paid work sooner," Dagher explains. Only 41 percent of women in the study had access to paid maternity leave, and the average duration of leave taken was 7.64 weeks. There is no national paid-leave policy in the United States, and while the Family and Medical Leave Act provides up to 12 weeks of unpaid leave to eligible employees, many women are not covered. Women in the U.S. return to paid work quickly after birth, with 69 percent of those surveyed returning within six months.

The study, which uses national data from the Listening to Mothers II survey of women across the United States, also found that 62 percent of all women surveyed reported some symptoms of depression after childbirth. An examination of the relationship between maternal depression and the length of maternity leave revealed that depression did not have an effect on return to work for mothers with unintended pregnancies. However, among women with an intended pregnancy, depressed mothers return to paid work more quickly than nondepressed mothers. The authors suggest that depressed mothers may find that staying home with a newborn decreases their sense of control and paid work becomes more attractive, or that women who are forced to return to work quickly may feel depressed about having to do so because of their economic circumstances.

Leave from work after childbirth provides mothers time for emotional recovery and for bonding with the baby, and returning to paid work sooner than desired may worsen depressive symptoms. Based on this and the findings of this study, the authors suggest that health care providers may want to advise women on the optimum amount of leave to take after childbirth given their mental health state.

They also encourage primary care providers and policymakers to support and implement policies that increase access to and utilization of effective contraceptive methods.

“Maternal Depression, Pregnancy Intention, and Return to Paid Work After Childbirth” was written by Rada K. Dagher, Sandra L. Hofferth and Yoonjoo Lee and published in Women’s Health Issues, Volume 24, Issue 3, Pages e297–e303, May–June, 2014.

University of Maryland

Simple paper test can help identify depressed teenagers

Simple paper test can help identify depressed teenagers

A few minutes spent filling out a widely accepted mental health assessment in a health care provider's waiting room could make a big difference for some teenagers suffering from depression, according to new study from a nursing researcher at The University of Texas at Arlington.

Sharolyn Dihigo, a nurse practitioner and clinical assistant professor in the UT Arlington College of Nursing, recently examined available research to determine whether nurse practitioners and others in primary care settings should add a mental health screening to well visits for teenage patients. Her conclusion was that a simple paper test called a CES-DC would be a reliable, quick way of determining whether the practitioner should refer a teen for mental health support.

"Getting teens treatment when they need it is essential and has potentially life-saving benefits," said Dihigo, who is also interim director of UT Arlington's Doctor of Nursing Practice program. "Providing this test while a family waits for their appointment can overcome hesitation to talk about the feelings and behaviors linked to depression and lead to treatment success."

The study, called "Use of Screening Tools for Depression in Adolescents: An Evidence-based Systematic Review," appears in the May issue of Women's Healthcare: A Clinical Journal for NPs, a new peer-reviewed, online journal from the National Association of Nurse Practitioners in Women's Health.

Nationally, it's estimated that five to 20 percent of adolescents suffer from depression, but many don't receive the treatment they need. Both the National Association of Pediatric Nurse Practitioners and the American Academy of Pediatrics have promoted screening for mental health problems in primary care.

CES-DC is short for Center for Epidemiological Studies Depression Scale for Children. It is free and does not require extra training for those who administer the screening. It contains 20 questions about how much children experienced sleeplessness or unhappiness in the past week.

To complete her paper, Dihigo reviewed 14 studies done previously by other researchers. She is also working on a paper describing a pilot project that put these methods into action in her own clinic.

"Dr. Dihigo's systematic review of available evidence has identified a low-cost, simple assessment that she can confidently recommend because she has used it in her clinical practice," said Jennifer Gray, interim dean of the UT Arlington College of Nursing. "In combining research and practice, she is doing what we all aspire to do - make a difference in the lives of patients."

Could a commonly prescribed antidepressant slow onset of Alzheimer's?

Could a commonly prescribed antidepressant slow onset of Alzheimer's?

New research from the Washington University School of Medicine in St. Louis, MO, and the University of Pennsylvania finds that a commonly prescribed antidepressant may be effective at slowing onset of Alzheimer's disease.

The problems with memory and cognition caused by Alzheimer's are strongly influenced by a build-up of plaques in the brain. The plaques consist of amyloid beta - a protein that is produced as part of normal brain activity. Patients with Alzheimer's disease, however, have elevated levels of amyloid beta, which results in the protein clumping together as plaques.

A previous study by senior author John Cirrito, PhD, assistant professor of neurology at Washington University, suggested that the production of amyloid beta can be reduced by the chemical messenger serotonin.

Most antidepressants work by stimulating the flow of serotonin in the brain, which prompted Cirrito and first author Dr. Yvette Sheline to investigate antidepressants as a tool to control amyloid beta production.

As part of a 2011 study, they tested a range of antidepressants in mice genetically altered to develop Alzheimer's as they age. The mice in the trial were young and had not yet developed the brain plaques that characterize the disease. The researchers found that the antidepressants successfully reduced amyloid beta production in the mice by an average of 25% after 24 hours.

"Until we can more definitively prove that these drugs help slow or stop Alzheimer's in humans, the risks aren't worth it," says Cirrito.

In their new study - published in the journal Science Translational Medicine - the researchers administered the antidepressant citalopram to older mice who already had plaques in their brain. They then tracked the growth of plaques in the mice for 28 days using a technique called "two-photon imaging."

They found that citalopram halted the growth of the existing plaques, while formation of new plaques was reduced by 78%.

In a second phase of the experiment, 23 human subjects between the ages of 18 and 50 received a single dose of citalopram. The participants were not cognitively impaired or depressed. Over the 24 hours following the administration of the citalopram, samples of spinal fluid were taken from the participants.

The spinal fluid samples showed that amyloid beta production had dropped in the human participants by 37%.

"Antidepressants appear to be significantly reducing amyloid beta production, and that's exciting," says Cirrito.

"But while antidepressants generally are well tolerated," he continues, "they have risks and side effects. Until we can more definitively prove that these drugs help slow or stop Alzheimer's in humans, the risks aren't worth it. There is still much more work to do."

The next step for the team is to use mouse models again in an attempt to understand the molecular process that causes serotonin to halt the production of amyloid beta.

Dr. Sheline says the team also plans to study older adults who will be treated for 2 weeks with antidepressants.

"If we see a drop in levels of amyloid beta in their spinal fluid after 2 weeks," she explains, "then we will know that this beneficial reduction in amyloid beta is sustainable."

Last year, a study published in JAMA suggested that poor sleep quality may contribute to an increased build-up of amyloid beta plaques in the brains of older people. Meanwhile, a study published around the same time in the journal Neurology found an association between hardening of the arteries and the build-up of amyloid beta plaques in the brain.

Comparing effectiveness of duloxetine and fluoxetine in treatment of pediatric major depressive disorder

Comparing effectiveness of duloxetine and fluoxetine in treatment of pediatric major depressive disorder

Two studies of the anti-depressive drug duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), compared its effectiveness and safety to either fluoxetine or placebo in children and adolescents with major depressive disorder (MDD). The results of these first controlled trials of duloxetine in pediatric patients with MDD are published in Journal of Child and Adolescent Psychopharmacology, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers. The articles are available free on the Journal of Child and Adolescent Psychopharmacology website.

Graham Emslie, MD and coauthors evaluated the efficacy and safety of a fixed dose of duloxetine - either 60 mg or 30 mg once a day - versus 20 mg daily of fluoxetine or placebo in children ages 7-11 years and adolescents ages 12-17 years. In the article "A Double-Blind Efficacy and Safety Study of Duloxetine Fixed Doses in Children and Adolescents with Major Depressive Disorder" they compare the treatments based on worsening of suicidal ideation, emergence of suicidal behavior, and adverse effects including abnormal findings on an electrocardiogram and laboratory tests.

Sarah Atkinson, MD and colleagues compared a flexible dosing regimen of duloxetine (60-120 mg daily) to fluoxetine (20-40 mg daily) or placebo and reported measures from a depression rating scale and a suicide severity rating scale, as well as treatment-related adverse events, in the article "A Double-Blind Efficacy and Safety Study of Duloxetine Flexible Dosing in Children and Adolescents with Major Depressive Disorder".

Neither study found a significant difference in response between the two drugs and placebo. The authors suggest that this may be due to the complexity of these novel studies and offer observations that may direct the design of future investigations.

"Drs. Emslie and Atkinson and their colleagues took a fascinating approach towards testing the efficacy of a novel SNRI in the pediatric population," said Harold S. Koplewicz, MD, Editor-in-Chief of Journal of Child and Adolescent Psychopharmacology, and President, Child Mind Institute, New York, NY. "Researchers are of course excited by positive results, but in this case the curious lack of response tells us volumes about how to better design complex studies - studies that may soon give us uncommon insight into our pharmacologic interventions."

Nationwide interest in cost-saving, coordinated brain care model for older adults

Nationwide interest in cost-saving, coordinated brain care model for older adults

The patient and caregiver-centered Aging Brain Care program, developed by researchers at the Regenstrief Institute and the Indiana University Center for Aging Research, is attracting nationwide interest for its ability to improve health outcomes and quality of care for those with cognitive impairment while dramatically lowering costs to patients and health care systems.

On May 22 and 23, a team of physicians and nurse managers from the Geisel School of Medicine at Dartmouth and the Dartmouth-Hitchcock Medical Center will visit Indianapolis and Lafayette, Ind., to learn more about the innovative Aging Brain Care model - ABC for short - and how implementation science is bringing rapid health improvement to older adults at lower cost. In June, a team from the Center for Health Innovation and Implementation Science and the ABC program will travel to New Hampshire to follow up with on-site training at Dartmouth.

"Our goal is no less than to transform how health care systems in communities across the nation provide care to these vulnerable patients - improving quality of life for older adults and saving money," said Malaz Boustani, M.D., MPH, who developed the ABC model. He is chief operating officer of the Center for Health Innovation and Implementation Science at Indiana University School of Medicine. The ABC model was the initial product of the Center for Health Innovation and Implementation Science and one of the center's growing number of population health management programs.

"Now that we have tested the ABC model in large clinical trials and shown that it improves care at a lower cost than standard care, we are training health care professionals from around the country in how to implement this patient- and caregiver-focused therapy at their own sites," Dr. Boustani said.

"By redesigning how older adults with dementia or depression are cared for, we are improving their lives and the lives of their caregivers, simultaneously saving an enormous of amount of health care dollars - conceivably billions of dollars nationwide," said Dr. Boustani, who is also chief innovation and implementation officer at Indiana University Health, a Regenstrief and an IU Center for Aging Research investigator, and an associate professor of medicine at the IU School of Medicine.

ABC, which can be adapted to a variety of care settings, is a team-based medical home dementia care model that supports and supplements the efforts of primary care providers. Using the tools, software and care protocols developed by Dr. Boustani and colleagues, the ABC team can identify, assess and manage the biopsychosocial needs of patients with dementia and their family caregivers with much greater success than usual care. The patient's primary care physician retains ultimate medical decision-making responsibility.

In January 2011, Dr. Boustani and colleagues published a study in Aging & Mental Health reporting that the ABC model reduces emergency department visits and hospitalizations, and successfully encourages use of medications that are not harmful to older brains. In a study published in a recent issue of the journal Health Affairs, the ABC model was shown to generate an annual net cost savings of up to $2,856 per patient. Both studies were conducted at Eskenazi Health (formerly Wishard Health), one of the nation's five largest safety net health systems, where the ABC model was first implemented.

Functional brain imaging enables empathy training

Functional brain imaging enables empathy training

Unprecedented research conducted by a group of neuroscientists has demonstrated for the first time that it is possible to train brain patterns associated with empathic feelings - more specifically, tenderness. The research showed that volunteers who received neurofeedback about their own brain activity patterns whilst being scanned inside a functional magnetic resonance (fMRI) machine were able to change brain network function of areas related to tenderness and affection felt toward loved ones. These significant findings could open new possibilities for treatment of clinical situations, such as antisocial personality disorder and postpartum depression.

In Ridley Scott's film "Blade Runner", based on the science fiction book 'Do androids dream of electric sheep?' by Philip K. Dick, empathy-detection devices are employed to measure tenderness or affection emotions felt toward others (called "affiliative" emotions). Despite recent advances in neurobiology and neurotechnology, it is unknown whether brain signatures of affiliative emotions can be decoded and voluntarily modulated.

The article entitled "Voluntary enhancement of neural signatures of affiliative emotion using fMRI neurofeedback" published in PLOS ONE is the first study to demonstrate through a neurotechnology tool, real-time neurofeedback using functional Magnetic Resonance Imaging (fMRI), the possibility to help the induction of empathic brain states.

The authors conducted this research at the D'Or Institute for Research and Education where a sophisticated computational tool was designed and used to allow the participants to modulate their own brain activity related to affiliative emotions and enhance this activity. This method employed pattern-detection algorithms, called "support vector machines" to classify complex activity patterns arising simultaneously from tenths of thousands of voxels (the 3-D equivalent of pixels) inside the participants' brains.

Volunteers who received real time information of their ongoing neural activity could change brain network function among connected areas related to tenderness and affection felt toward loved ones, while the control group who performed the same fMRI task without neurofeedback did not show such improvement.

Thus, it was demonstrated that those who received a "real" feedback were able to "train" specific brain areas related to the experience of affiliative emotions that are key for empathy. These findings can lead the way to new opportunities to investigate the use of neurofeedback in conditions associated with reduced empathy and affiliative feelings, such as antisocial personality disorders and post-partum depression.

The authors point out that this study may represent a step towards the construction of the 'empathy box', an empathy-enhancing machine described by Philip K. Dick's novel.

The paper can be found in PLOS ONE website on May 21, 2014.

The study was supported by Foundation for Research Support in the State of Rio de Janeiro (FAPERJ) and D'Or Institute for Research and Education (IDOR).

Instituto D'Or de Pesquisa e Ensino (IDOR)

Meditation training may help reduce stress disorders among US military personnel

Meditation training may help reduce stress disorders among US military personnel

Researchers from the University of California, San Diego School of Medicine and Naval Health Research Center have found that mindfulness training - a combination of meditation and body awareness exercises - can help U.S. Marine Corps personnel prepare for and recover from stressful combat situations.

The study, published in th online issue of the American Journal of Psychiatry, suggests that incorporating meditative practices into pre-deployment training might be a way to help the U.S. military reduce rising rates of stress-related health conditions, including PTSD, depression and anxiety, within its ranks.

"Mindfulness training won't make combat easier," said Martin Paulus, MD, professor of psychiatry and senior author. "But we think it can help Marines recover from stress and return to baseline functioning more quickly."

Drawing on the teachings of Zen Buddhism, scientists describe mindfulnes as a mental state characterized by "full attention to the present moment without elaboration, judgment or emotional reactivity." Mindfulness training, traditionally practiced through sitting meditation, attempts to cultivate this mental state by quieting the mind of extraneous thoughts.

The bar graph shows that US military personnel who received mindfulness training (red) had reduced activity in a region of the brain knowns as the insula, also known as the insular cortex, which acts as the brain's connector strip. Meditation appears to change how people's brains respond to and recover from highly stressful events.
Credit: UC San Diego School of Medicine

In the study, Marine infantrymen in four platoons at Marine Corps Base Camp Pendleton took an eight-week course in mindfulness, tailored for individuals operating in highly stressful environments.

The course included classroom instruction on meditation and homework exercises, as well as training on interoception - the ability to help the body regulate its overall physical equilibrium (homeostasis) by becoming aware of bodily sensations, such as tightness in the stomach, heart rate and tingling of the skin.

"If you become aware of tightness in your stomach, your brain will automatically work to correct that tightness," Paulus explained.

Participating Marines, along with others who had not undergone mindfulness training, then spent a day in mock immersive combat at a 32,000-square-foot training facility staged to resemble a rural Middle Eastern village. During the day's exercises, Marines patrolled the village, met village leadership and responded to a highly realistic ambush.

The scientists found that the heart and breathing rates of those who had received mindfulness training returned to their normal, baseline levels faster than those who had not received the mindfulness training. Blood levels of a tell-tale neuropeptide suggested that the mindfulness-trained Marines experienced improved immune function, as well.

Subsequent magnetic resonance imaging scans revealed that the mindfulness-trained Marines had reduced activity patterns in regions of the brain responsible for integrating emotional reactivity, cognition and interoception. Lori Haase, a postdoctoral fellow in Paulus' lab and a co-author of the study, said similar brain activity patterns had been observed in high performance athletes and Navy seals. High-activity levels in these areas of the brain, she noted, are associated with anxiety and mood disorders. The scientists hypothesize that reduced brain activity in the anterior insula and anterior cingulate may be characteristic of elite performers in general.

"That we can re-regulate the activity in these areas with so little training is this study's most significant finding," Paulus said. "Mindfulness helps the body optimize its response to stress by helping the body interpret stressful events as bodily sensations. The brain adds less emotional affect to experiences and this helps with stress recovery."

This research was funded, in part, by the Office of Naval Research Code 30 and Navy Bureau of Medicine and Surgery.

Co-authors include Douglas Johnson, Naval Health Research Center, Warfighter Performance Department and UCSD Department of Psychiatry; Nate Thom, Naval Health Research Center, Warfighter Performance Department; Elizabeth Stanley, Walsh School of Foreign Service, Georgetown University and Mind Fitness Training Institute; Alan Simmons, Pei-an Shih and Wesley Thompson, UCSD Department of Psychiatry; Thomas Minor, UCLA Department of Psychology; Eric Potterat, Naval Special Warfare Command.

University of California - San Diego

Study suggests more maternal mental health surveillance needed

Study suggests more maternal mental health surveillance needed

Maternal depression is more common at four years following childbirth than at any other time in the first 12 months after childbirth, and there needs to be a greater focus on maternal mental health, suggests a new study published in BJOG: An International Journal of Obstetrics and Gynaecology.

The study using data from 1507 women from six public hospitals in Melbourne, Australia, examines the prevalence of maternal depression from early pregnancy to four years postpartum. The researchers identify the possible risk factors for depressive symptoms at four years postpartum, including previous depression, relationship transitions, intimate partner violence and social adversity.

Questionnaires were completed at recruitment and at 3, 6, 12, 18 months postpartum and four years postpartum. The Edinburgh Postnatal Depression Scale was used in the questionnaire and intimate partner abuse was assessed at 12 months postpartum and at four years using the Composite Abuse Scale.

Results show that almost one in three women reported depressive symptoms in the first four years after birth. The prevalence of depressive symptoms at four years postpartum was 14.5%, and was higher than at any time-point in the first 12 months postpartum.

Furthermore, women with one child at four years postpartum were more than twice as likely to report depressive symptoms at this time compared to women with subsequent children (22.9% and 11.3% respectively).

The strongest predictor of depressive symptoms at four years postpartum was having previously reported depressive symptoms either in early pregnancy or in the first 12 months after childbirth. Other factors associated with depressive symptoms were; young maternal age (18-24 years), stressful life events/social adversity in the year prior to the four year follow-up, intimate partner violence and low income. Exposure to intimate partner abuse in the first 12 months postpartum or in the year prior to the four year follow-up was associated with a four-fold increase in odds of reporting depressive symptoms at four years postpartum.

The authors emphasise a need for current services to extend surveillance of maternal mental health to cover the early years of parenting and recommend the integration of core mental health services within routine primary healthcare (antenatal and postnatal visits).

Dr Hannah Woolhouse, psychologist and Senior Research Officer, from the Murdoch Childrens Research Institute, Victoria, Australia and co-author said:

"These findings provide a compelling case for re-thinking current policy frameworks for maternal mental health surveillance.

"It is likely that current systems of maternal mental health surveillance in Australia and the UK will miss more than half the women experiencing depression in the early years of parenting. In particular, women who do not have subsequent children may be especially vulnerable to falling through the gaps as they will not be reconnected back into primary care services.

"There also needs to be a focus on social health and relationships as we have found a strong link between depressive symptoms and intimate partner violence."

John Thorp, BJOG Editor-in-chief added:

"Much research has been conducted around maternal mental health during the perinatal period, however, we know very little about the prevalence of maternal depression after the first 12 months of giving birth.

"The findings of this study reinforce the need for an increased focus on maternal health, particularly in the long term, as current guidance for professionals focuses on pregnancy and the early months after birth, and the need to take into account factors linked to the mother's life."

Children suffer for years after their single mothers are laid off

Children suffer for years after their single mothers are laid off

When single mothers lose their jobs, their children suffer significant negative effects as young adults, according to a new study by researchers at the California Center for Population Research at UCLA.

The study focused on two sets of outcomes for the children - educational achievement and social-psychological well-being. Specifically, researchers evaluated whether those in the study had graduated from high school by age 19, attended college by age 21 and graduated from college by age 25; and whether they exhibited symptoms of depression between the ages of 20 and 24 and between the ages of 25 and 29.

"The findings are alarming, and they suggest we should be doing more to ensure that these children don't get lost in the shuffle," said lead author Jennie Brand, associate director of the research center and associate professor of sociology at UCLA. "Through no fault of their own, they appear to be paying years down the line for their mothers' employment issues."

The study will be published Friday by the American Journal of Sociology.

Analyzing 30 years of data from the U.S. Bureau of Labor Statistics, the researchers compared outcomes in young adulthood for children whose mothers were laid off during the child's first 17 years and children whose mothers were not laid off during that time. The children of mothers who were laid off were 15 percent less likely to complete high school than children whose moms were not laid off. They also were 24 percent less likely to attend college and 33 percent less likely to graduate from college.

Symptoms of depression were measured according to the Center for Epidemiological Studies Depression Scale, which asks respondents to categorize how frequently they had a poor appetite, difficulty sleeping, trouble getting motivated and experienced four other symptoms. When children reached their late 20s, those whose mothers had been displaced were significantly more likely to have symptoms of depression compared with the levels expected for children whose mothers had not been displaced.

A theory in the field of childhood development suggests that socioeconomic adversity can have a particularly damaging long-term effect on children if it occurs in early childhood, but the UCLA study found no negative effects among children who were 5 or younger when their moms lost their jobs.

In fact, the negative effects of the mother's job loss were greatest among older children. Children who were between 12 and 17 when the job loss occurred were 40 percent less likely to graduate from high school, 25 percent less likely to attend college and 45 percent less likely to graduate from college, compared with children whose moms remained employed during that time. Children whose mothers lost jobs when the children were between 12 and 17 years old showed significant symptoms of depression in their 20s, but those symptoms were more pronounced in the children's late 20s if their moms were displaced when they were ages 6 to 11.

A single mother's job loss had particularly strong effects on the child if the mother had an otherwise steady job history and didn't expect to lose her job, and if the mother was laid off during a period when the economy was strong.

Brand said that might be because children whose mothers had unstable employment histories may have viewed the layoff as somewhat less of a shock. "Perhaps greater internalization of blame and social stigma among mothers who hadn't expected to lose their jobs contributes to larger negative effects on their children," she said.

The psychological effects of the recent U.S. recession and the resulting unemployment for millions of workers have been studied extensively, but few studies have considered how a parent's job loss affects children over the long term. Fewer still have considered the effects on children in single-parent households, a group particularly vulnerable to economic shocks. Since at least half of all children spend some portion of their childhoods raised by a single mother, the well-being of single-mother families is a fundamental concern, said Brand, who is on the faculty of UCLA's College of Letters and Science.

The research indicates that employment instability can carry from one generation to the next, Brand said. "Our study shows that the children of displaced mothers struggle educationally and psychologically for many years afterward, and thus are themselves more likely to suffer from employment instability."

Brand also said the findings should be a part of the conversation among public policy makers who determine employment assistance and welfare programs. "Debates about social assistance should acknowledge that involuntary job separation among single mothers has significant implications for the next generation," she said.

'Alternative teens nearly 7 times more likely to attempt suicide'

'Alternative teens nearly 7 times more likely to attempt suicide'

Almost half of "alternative" teenagers - that is, teens identifying as belonging to goth, emo and punk subcultures - self-harm, and nearly 1 in 5 have attempted suicide, according to new research.

In previous research, the lead author behind the new study - Robert Young, senior investigative scientist at the Medical Research Council (MRC) Social and Public Health Sciences Unit at University of Glasgow in the UK - found an association between self-harm and teenagers in Glasgow who identify with the goth subculture.

In that study, Young reported that 53.5% of the goths he studied in Glasgow engaged in non-suicidal self-harm, and 47% claimed that they had attempted suicide.

With the new study - which is published in BMC Psychiatry - Young's team partnered with researchers from the University of Ulm in Germany to investigate the reasons why teenagers in certain subcultures are more likely to self-harm or attempt suicide.

The researchers studied 452 German school pupils aged 14-15. The pupils were asked to describe how strongly they identified with specific youth cultures, such as alternative, "nerd," or "jock."

The study also collected data from the students on their gender, immigration status, their parent's social and economic status and any physical bullying or verbal harassment they experience - all of which are risk factors strongly linked to self-harm.

Young and his team found that teenagers identifying as alternative (defined here as being goth, emo or punk) were 3-4 times more likely to self-injure and 6-7 times more likely to attempt suicide than other teenagers.

The study reports that identifying with the alternative subculture is a stronger predictor for teenage self-injury or attempted suicide than being repeatedly bullied.

Athletic teenagers who identified as "jocks" were the group least likely to self-injure, according to the study. The researchers wonder if this may be influenced by the effect of regular physical activity, which is known to improve depression symptoms in adults.

Despite being stereotyped as socially excluded, academic or "nerd" teenagers were found to be no more likely to self-injure or attempt suicide than any other teenage group.

Academic or "nerd" teenagers, meanwhile, were found to be no more likely to self-injure or attempt suicide than any other teenage group. The authors consider this surprising, as the nerd stereotype is often associated with bullying and peer exclusion.

"Our research supports the notion that social mechanisms influence self-harm," says Young. "This is a crucial finding when thinking of ways to address and prevent self-harm in adolescence."

Although previous research has suggested that there may be a "socially contagious" element to self-injury - as the majority of adolescents in these studies were found to have friends who also self-injure - the new study found that only a minority of teenagers self-injure in an attempt to "feel more part of a group."

"It may well be that building on the strong identification with a certain kind of music or youth group, therapeutic approaches such as music therapy, in combination with strategies to decrease distress, are a feasible option for addressing self-harm," considers Young.

Commenting on the study, Prof. David Lomas, chair of the MRC Population and Systems Medicine Board, says:

"Global estimates suggest 30% of all teenagers have suicidal thoughts, 18% have self-injured and 4% actually attempt suicide, and the overall rates in this study were typical for this age group (26%, 21% and 4%, respectively). Understanding the reason why different groups of teenagers self-injure will hopefully lead to early detection and help develop effective interventions for those at risk from self-injury or suicide."

Parental abuse of alcohol increases risk of suicide by adult offspring

Parental abuse of alcohol increases risk of suicide by adult offspring

People who grew up with a parent who abused alcohol may be 85 percent more likely to attempt suicide than people whose parents did not abuse alcohol, according to research published by the American Psychological Association.

Furthermore, having divorced parents increased by 14 percent the risk that a person would try to take his or her own life when compared to people whose parents did not divorce, the study found. But putting those two factors together - parents who abuse alcohol and are divorced -- did not increase suicide attempts, according to the study, coming out in the May issue of APA's American Journal of Orthopsychiatry.

"These findings underscore the need for comprehensive client and family assessments by clinicians to identify people in particular need of early interventions," said lead author Dana Alonzo, PhD, of Columbia University. "Individuals whose parents were divorced or abused alcohol might be more vulnerable for suicide than those from intact or nonalcoholic households. Prevention and treatment efforts need to target groups that are accurately identified as at risk."

Researchers examined data from a 2001-2002 Department of Health and Human Services survey of 43,093 people 18 years old or older who were interviewed in person. A total of 13,753 participants reported they had suffered major depression at some point in their life and of those, 1,073 said they had attempted suicide. In the group that reported attempted suicide, 25 percent said they had parents who divorced and 46 percent said one or both parents abused alcohol. From the full sample, 2.4 percent reported a suicide attempt, 16 percent reported their parents were divorced and 21 percent said at least one parent had abused alcohol.

As for why homes disrupted by a combination of divorce and drinking didn't lead to more risk of attempted suicides, the authors speculated that divorce may have decreased hostility at home and therefore didn't contribute to a child's becoming a maladjusted adult. "Or, it may be that children with an alcoholic parent are not as surprised when their parents split up because they have already witnessed so much conflict, so it may not lead to as much confusion and resentment as it might in a better-functioning family," Alonzo said.

The researchers assessed participants' history of depression by asking if they ever felt sad over a period lasting at least two weeks; had they stopped caring about things important to them; or did they no longer enjoy their favorite things. Other questions were based on the Diagnostic and Statistical Manual for Mental Disorders (DSM) criteria for depression. To determine if a participant's parent had abused alcohol, researchers read definitions from the DSM criteria for alcohol abuse, including readily observable behaviors, and asked participants if they had witnessed those behaviors by their mother or father.

The study was the first with a nationally representative sample to examine whether having divorced parents or a parent who abused alcohol affects the likelihood of suicide attempts, according to the authors.

The full sample was 48 percent male, 71 percent white, 11 percent black, 2 percent Native American, 4 percent Asian-American and 12 percent Hispanic. In terms of age, 22 percent were 18 to 29, 31 percent were 30 to 44, 31 percent were 45 to 64 and 16 percent were 65 or older. People married or living with someone accounted for 62 percent, 17 percent were widowed, separated or divorced and 21 percent were never married. Regarding education, 16 percent had not graduated from high school, 29 percent had a high school degree and 55 percent had attended some college.

Article: "The Influence of Parental Divorce and Alcohol Abuse on Adult Offspring Risk of Lifetime Suicide Attempt in the United States," Dana Alonzo, PhD, and G. Thompson, PhD, Columbia University; Malka Stohl, MS, New York State Psychiatric Institute; Deborah Hasin, PhD, Columbia University and New York State Psychiatric Institute, American Journal of Orthopsychiatry, May 2014. 2014, Vol. 84, No. 3, 316–320 DOI: 10.1037/h0099804

American Psychological Association

Behavioral problems often manifest in children when their preschool teacher is depressed

Behavioral problems often manifest in children when their preschool teacher is depressed

Depression in preschool teachers is associated with behavioral problems ranging from aggression to sadness in children under the teachers' care, new research suggests.

The study identified one contributing factor to this link: a poor-quality atmosphere in the child care setting that exists as a result of the teacher's depressive symptoms. In this study, "teacher" refers to both classroom instructors and in-home child care providers.

Researchers conducted the study using data from a large national study that collected family information primarily from low-income, single-mother households.

"We were interested in that sample because we thought that children of low-income single mothers might experience a more emotionally vulnerable home environment, and we wanted to see if the role of teachers affected their psychological health," said Lieny Jeon, lead author of the study and a postdoctoral researcher in human sciences at The Ohio State University.

Behavioral problems in young children - in this case, 3-year-olds - can result in later issues that include lower academic achievement and a lack of social skills, according to previous research. The problems rated in this study included externalizing behaviors such as aggression, anger and a lack of control, as well as internalizing behaviors: depression, anxiety, sadness and withdrawal.

Jeon and colleagues aim to develop an intervention allowing teachers to address their own psychological needs - all in the name of giving children the best chance for appropriate behavioral development.

"We know high-quality early childhood education is critical and we also know that very few programs in the United States are truly high in quality. So how do we get there?" said Cynthia Buettner, associate professor of human sciences at Ohio State and senior author of the paper. "It's incredibly important. Teachers can have a really big impact on children's development."

The research is published in the current issue of the Journal of Consulting and Clinical Psychology.

The study sample came from the Fragile Families and Child Wellbeing Study, an ongoing large, federally funded examination of single-parent families living under low socioeconomic conditions in 20 large U.S. cities. The study contains data from families in 15 cities that reported using child care services for 3-year-old children for at least five hours per week. In a supplemental study, a research team surveyed the teachers of those children and observed their child care environments. A total of 761 families and teachers from the national data are represented in Jeon's analysis.

Teachers completed a survey that rated their depressed mood during the preceding two weeks. Assessments of the quality of the child care atmosphere looked at space and furnishings, personal care, learning activities, social interactions and discipline.

Compiling a number of factors from this broad national data, Jeon applied statistical analysis to the variables and developed a model describing the relationships between teacher depression and childhood behavioral outcomes. The behavioral problems in children had been scored separately by both mothers and teachers.

The analysis showed a direct relationship between teacher depression and both externalizing and internalizing problems in children reported by teachers as well as internalizing problems reported by parents. The teacher depression did not predict externalizing problems as reported by the children's mothers.

"We were interested in responses about behavior from both mothers and teachers because they sometimes disagree on these issues, perhaps because they see children in different environments," Jeon said. "The significant association between teacher depression and internalizing problems at home could be because kids are modeling the teachers' negative moods."

The study also showed that when the quality of the child care climate - in a home or an educational center - was factored into the analysis, the relationship between teacher depression and parent-reported behaviors changed. Teacher depression predicted an overall lower-quality child care atmosphere, which in turn predicted teacher-reported externalizing and internalizing problems among the children. In this case, however, the poor-quality child care climate linked to teacher depression did not predict mother-reported behavioral problems.

"This path between teacher depression and childhood behavioral problems can likely be explained in several ways. One of the reasons this relationship manifests with behavior problems is because the classroom has an unhealthy climate," Jeon said.

Jeon is extending her work by surveying preschool teachers about how depression and other factors contribute to their overall social and emotional capacity - a term coined by the research team. She is asking them about their work environment, relationship to colleagues, pay and benefits, coping strategies, commitment to professional development and attitudes about children. Once she has data on these aspects of teacher life, she hopes to develop a way for teachers to spend some time looking after themselves.

"Most training for teachers is about managing the classroom and addressing behavioral problems," Jeon said. "They don't have the time or resources to address their own psychological difficulties, or access to any specialized mental health services."

Salary is a considerable issue for this population, Jeon and Buettner noted. The average annual pay for a preschool teacher is $27,130.

"There's a real mismatch between the expectations for teachers and what they get paid," Buettner said. "They're frequently low-paid positions with not a lot of respect for the work people do."

By: Emily Caldwell

Buettner is the principal investigator on one resource that is intended to improve early childhood education in the United States. The Virtual Laboratory School, funded by the Department of Defense, is an online training system allowing professionals to build their knowledge and skills around best practices in child care and youth development. The entire program is scheduled to be available by early 2015.

The Fragile Families and Child Wellbeing Study is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Jeon and Buettner completed the work with co-author Anastasia Snyder, interim chair of human sciences at Ohio State.

Ohio State University

Mental health conditions increase likelihood of using e-cigarettes

Mental health conditions increase likelihood of using e-cigarettes

Researchers at University of California, San Diego School of Medicine report that people living with depression, anxiety or other mental health conditions are twice as likely to have tried e-cigarettes and three times as likely to be current users of the controversial battery-powered nicotine-delivery devices, as people without mental health disorders.

They are also more susceptible to trying e-cigarettes in the future in the belief that doing so will help them quit, the scientists said. The FDA has not approved e-cigarettes as a smoking cessation aid.

The study was published in the online issue of Tobacco Control.

"The faces of smokers in America in the 1960s were the 'Mad Men' in business suits," said lead author Sharon Cummins, PhD, assistant professor in the Department of Family and Preventive Medicine. "They were fashionable and had disposable income. Those with a smoking habit today are poorer, have less education, and, as this study shows, have higher rates of mental health conditions."

By some estimates, people with psychiatric disorders consume approximately 30 to 50 percent of all cigarettes sold annually in the U.S.

"Since the safety of e-cigarettes is still unknown, their use by nonsmokers could put them at risk," Cummins said. Another concern is that the widespread use of e-cigarettes could reverse the social norms that have made smoking largely socially unacceptable.

The study shows that smokers, regardless of their mental health condition, are the primary consumers of the nicotine delivery technology. People with mental health disorders also appear to be using e-cigarettes for the same reasons as other smokers - to reduce potential harm to their health and to help them break the habit.

"So far, nonsmokers with mental health disorders are not picking up e-cigarettes as a gateway to smoking," Cummins said.

The study is based on a survey of Americans' smoking history, efforts to quit and their use and perceptions about e-cigarettes. People were also asked whether they had ever been diagnosed with an anxiety disorder, depression or other mental health condition.

Among the 10,041 people who responded to the survey, 27.8 percent of current smokers had self-reported mental health conditions, compared with 13.4 percent of non-smokers; 14.8 percent of individuals with mental health conditions had tried e-cigarettes, and 3.1 percent were currently using them, compared with 6.6 percent and 1.1 percent without mental health conditions, respectively.

In addition, 60.5 percent of smokers with mental health conditions indicated that they were somewhat likely or very likely to try e-cigarettes in the future, compared with 45.3 percent of smokers without mental health conditions.

"People with mental health conditions have largely been forgotten in the war on smoking," Cummins said. "But because they are high consumers of cigarettes, they have the most to gain or lose from the e-cigarette phenomenon. Which way it goes will depend on what product regulations are put into effect and whether e-cigarettes ultimately prove to be useful in helping smokers quit."

Co-authors of this study include Shu-Hong Zhu and Anthony C. Gamst, Department of Family and Preventive Medicine, UCSD; Gary J. Tedeschi, UC San Diego Moores Cancer Center; and Mark G. Myers, Department of Psychiatry, UCSD.

Funding for this research came from the National Cancer Institute (grant U01 CA154280).

University of California - San Diego

Research study available for older adults living with low back pain and depression

Research study available for older adults living with low back pain and depression

Older adults experiencing chronic low back pain and depression are invited to participate in the final year of a five-year study that aims to find out whether medication alone or medication along with health coaching and learning new problem-solving skills is best for treating both conditions. The "Addressing Depression and Pain Together," or ADAPT study, is an effort led by researchers at the University of Pittsburgh School of Medicine.

Both low back pain and clinical depression are common in seniors, and up to 25 percent of older adults suffer from both conditions at the same time, said principal investigator Jordan F. Karp, M.D., associate professor of psychiatry, University of Pittsburgh School of Medicine.

"Chronic low back pain and depression make each other worse, have similar risk factors, and increase the likelihood of each other's recurrence," he said. "Both can cause poor sleep and subsequent daytime drowsiness, keep people from participating or enjoying their usual activities, and isolate them at home. When they are both present, patients can enter a vicious cycle of the blues, pain, physical deconditioning, and feeling hopeless."

For the ADAPT study, adults 60 or older who have depression symptoms and low back pain on most days for at least three months will participate in the first stage during which everyone takes the anti-depressant drug venlafaxine, also known as Effexor. Participants who have not improved after the first six weeks then have the opportunity to continue in the study for an additional 14 weeks, and be randomly assigned to receive a higher dose of venlafaxine alone or in combination with a counseling program that teaches problem-solving skills specific for managing pain, mood, sleep, and other difficulties commonly experienced by seniors living with these linked conditions.

At low doses, venlafaxine increases the levels of the neurotransmitter serotonin, which regulates mood. At higher doses, the drug also increases levels of the neurotransmitter norepinephrine, which regulates both mood and pain, Dr. Karp said.

"Venlafaxine has been approved for the treatment of anxiety and depression, and it is a widely used, well-tolerated drug," he said. "Getting people moving and in better control of their pain through healthy behavior changes also may help their mood and improve quality of life."

According to Dr. Karp, the goal of the study is to learn whether people who do not improve with low-dose venlafaxine alone need the addition of the problem-solving therapy to get them feeling better.