In clinical samples, comorbidity between depressive and anxiety disorders is associated with greater symptom severity and elevated suicide risk. Less is known, however, regarding the long-term psychosocial impact that a lifetime history of both MDD and one or more anxiety disorders has in community samples. This report evaluates clinical, psychological, social, and stress-related characteristics associated with a lifetime history of MDD and anxiety.
Data from 915 women aged 42–52 who were recruited as part of the the Study of Women's Health Across the Nation Mental Health Study were used to examine clinical and psychosocial features across groups of women with a SCID-diagnosed lifetime history of MDD alone, anxiety alone, both MDD and anxiety, or neither MDD nor anxiety.
As compared with women with a history of either MDD or anxiety alone, women with a comorbid history were more likely to report recurrent MDD, multiple and more severe lifetime anxiety disorders, greater depressive and anxiety symptoms, diminished social support, and more past-year distressing life events. Exploratory analyses indicated that women with a comorbid history also report more childhood abuse/neglect and diminished self-esteem, as compared with women with a history of either disorder alone.
Midlife women with a comorbid history that includes both MDD and anxiety disorders report diminished social support, more symptomatic distress, and a more severe and recurrent psychiatric history. Future research is needed to clarify the biological and psychosocial risk factors associated with this comorobid profile, and to develop targeted interventions for this at-risk group.
major depressive disorder; anxiety disorders; comorbidity; child abuse; social support; stress, psychological
Little is known about the independent associations of reward and stress within specific roles with multiple measures of mental health in an ethnically diverse community sample of midlife women. The objective of this study is to examine if (1) role reward (within each role and across roles) contributes directly to mental health and buffers the negative impact of role stress and (2) associations among role occupancy, role stress, and role reward and mental health vary by race/ethnicity.
With separate logistic regression analysis, we investigated cross-sectional relationships between role stress and role reward with presence/absence of high depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D≥16]), anxiety symptoms (feeling tense or nervous, irritable or grouchy, fearful for no reason, and heart pounding or racing total score≥4), or low social functioning (bottom 25th percentile of the Short-Form-36 [SF-36] social functioning subscale) in 2549 women participating in the third visit of the Study of Women's Health Across the Nation (SWAN), a longitudinal population-based study of menopause.
High reward across roles attenuated the negative impact of role stress on social functioning but not on anxiety or depression. High reward marriage buffered the impact of marital stress on depression, and high reward mothering buffered the effect of maternal stress on depression and social functioning. Compared to Caucasians, Hispanics and Chinese with high stress across roles had better social functioning, and African American mothers had lower odds of high depressive symptoms.
Role reward buffers the negative impact of stress on social functioning and depression, but not on anxiety. Minorities may respond to role stress by seeking social support.
It is unclear whether risk for major depression during the menopausal transition or immediately thereafter is increased relative to premenopause.
To examine whether the odds of experiencing major depression were greater when women were perimenopausal or postmenopausal compared to when they were premenopausal, independent of a history of major depression at study entry and annual measures of vasomotor symptoms, serum levels or changes in estradiol, follicular stimulating hormone, or testosterone and relevant confounders.
Participants included the 221 African American and Caucasian women, aged 42–52, who were premenopausal at entry into the Pittsburgh site of a community-based study of menopause, the Study of Women’s Health Across the Nation (SWAN). We conducted the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) to assess diagnoses of lifetime, annual, and current major depression at baseline and annual follow-ups. Psychosocial and health factors, and blood samples for assay of reproductive hormones were obtained annually.
Women were two to four times more likely to experience major depression episode when they were perimenopausal or early postmenopausal. Repeated measures logistic regression analyses showed that the effect of menopausal status was independent of history of major depression and annually measured upsetting life events, psychotropic medication use, vasomotor symptoms and serum levels of or changes in reproductive hormones. History of major depression was a strong predictor of major depression throughout the study.
The risk of major depression is greater for women during and immediately after the menopausal transition than when they are premenopausal.
Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first-line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non-response to escitalopram monotherapy of unipolar MDD in later life.
One hundred and seventy-five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co-existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open-label escitalopram and were divided into full (n =55; 31%), partial (n =75; 42.9%), and non-responder (n =45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups.
Non-responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self-esteem than full responders. In general partial responders resembled full responders more than they resembled non-responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self-esteem predicted worse response status at 6 weeks.
Among treatment-seeking elderly persons with MDD, higher anxiety symptoms and lower self-esteem predict poorer response after six weeks of escitalopram treatment.
major depression; old age; escitalopram; treatment response
Adolescents, elderly persons, African Americans, and rural residents with bipolar disorder are less likely than their middle-aged, white, urban counterparts to be diagnosed, receive adequate treatment, remain in treatment once identified, and have positive outcomes. The Bipolar Disorder Center for Pennsylvanians (BDCP) study was designed to address these disparities. This report highlights the methods used to recruit, screen, and enroll a cohort of difficult-to-recruit individuals with bipolar disorder.
Study sites included three specialty clinics for bipolar disorder in a university setting and a rural behavioral health clinic. Study operations were standardized, and all study personnel were trained in study procedures. Several strategies were used for recruitment.
It was possible to introduce the identical assessment and screening protocol in settings regardless of whether they had a history of implementing research protocols. This protocol was also able to be used across the age spectrum, in urban and rural areas, and in a racially diverse cohort of participants. Across the four sites 515 individuals with bipolar disorder were enrolled as a result of these methods (69 African Americans and 446 non–African Americans). Although clinical characteristics at study entry did not differ appreciably between African Americans and non–African Americans, the pathways into treatment differed significantly.
Rigorous recruitment and assessment procedures can be successfully introduced in different settings and with different patient cohorts, thus facilitating access to high-quality treatment for individuals who frequently do not receive appropriate care for bipolar disorder.
Since the Pap test was introduced in the 1940s, there has been an approximately 70% reduction in the incidence of squamous cell cervical cancers in many developed countries by the application of organized and opportunistic screening programs. The efficacy of the Pap test, however, is hampered by high interobserver variability and high false-negative and false-positive rates. The use of biomarkers has demonstrated the ability to overcome these issues, leading to improved positive predictive value of cervical screening results. In addition, the introduction of HPV primary screening programs will necessitate the use of a follow-up test with high specificity to triage the high number of HPV-positive tests. This paper will focus on protein biomarkers currently available for use in cervical cancer screening, which appear to improve the detection of women at greatest risk for developing cervical cancer, including Ki-67, p16INK4a, BD ProEx C, and Cytoactiv HPV L1.
Stigma associated with mental illness continues to be a significant barrier to help seeking, leading to negative attitudes about mental health treatment and deterring individuals who need services from seeking care. This study examined the impact of public stigma (negative attitudes held by the public) and internalized stigma (negative attitudes held by stigmatized individuals about themselves) on racial differences in treatment seeking attitudes and behaviors among older adults with depression.
Random digit dialing was utilized to identify a representative sample of 248 African American and White adults older adults (over the age of 60) with depression (symptoms assessed via the Patient Health Questionnaire-9). Telephone based surveys were conducted to assess their treatment seeking attitudes and behaviors, and the factors that impacted these behaviors.
Depressed older adult participants endorsed a high level of public stigma and were not likely to be currently engaged in, nor did they intend to seek mental health treatment. Results also suggested that African American older adults were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than their White counterparts. Multiple regression analysis indicated that internalized stigma partially mediated the relationship between race and attitudes toward treatment.
Stigma associated with having a mental illness has a negative influence on attitudes and intentions toward seeking mental health services among older adults with depression, particularly African American elders. Interventions to target internalized stigma are needed to help engage this population in psychosocial mental health treatments.
Stigma; Depression; Treatment; Aging
Depressive disorders are common, and it is important to understand the factors that contribute to racial disparities in depression treatment. This primary care study of veterans with subsyndromal depression examined two hypotheses: that African Americans would be less likely than Caucasians to believe that medication is beneficial in depression treatment and would be more likely to believe that counseling or psychotherapy is beneficial.
Primary care patients with subsyndromal depression were referred to the Philadelphia Department of Veterans Affairs Behavioral Health Laboratory and asked about past experiences and attitudes toward depression treatment.
Among 111 African-American and 95 Caucasian participants, logistic regression analyses determined that African Americans were less likely to view medication as beneficial (odds ratio=.44). No racial differences were found in participants’ attitude toward counseling or psychotherapy.
The findings support the premise that clinicians treating patients with subsyndromal depressive syndromes should take into account racial differences in attitudes toward treatment.
Depression among older adults is a major public health concern leading to increased disability and mortality. Less than 3% of older adults utilize professional mental health services for the treatment of depression, less than any other adult age group. And despite similar rates of depression, African Americans are significantly less likely to seek, engage and be retained in professional mental health services than their white counterparts. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may in part explain some of these racial differences in help-seeking behaviors. Focus group methodology was utilized to identify and explore attitudes and beliefs about depression and mental health treatment utilization among 42 older African Americans who had recently suffered a major depressive episode. Thematic analysis of identified six overarching themes: (a) perceptions of depression, (b) the African American experience, (c) seeking treatment as a last resort, (d) myths about treatment, (e) stigma associated with seeking treatment and (f) culturally appropriate coping strategies. We discuss implications for practice, education and research.
Aging; Depression; Stigma; Treatment
Older adults are particularly vulnerable to the effects of depression, however, they are less likely to seek and engage in mental health treatment. African-American older adults are even less likely than their White counterparts to seek and engage in mental health treatment. This qualitative study examined the experience of being depressed among African-American elders and their perceptions of barriers confronted when contemplating seeking mental health services. In addition, we examined how coping strategies are utilized by African-American elders who choose not to seek professional mental health services.
A total of 37 interviews were conducted with African-American elders endorsing at least mild symptoms of depression. Interviews were audiotaped and subsequently transcribed. Content analysis was utilized to analyze the qualitative data.
Thematic analysis of the interviews with African-American older adults is presented within three areas: (1) Beliefs about Depression Among Older African-Americans: (2) Barriers to Seeking Treatment for Older African-Americans: and (3) Cultural Coping Strategies for Depressed African-American Older Adults.
Older African-Americans in this study identified a number of experiences living in the Black community that impacted their treatment seeking attitudes and behaviors. which led to identification and utilization of more culturally endorsed coping strategies to deal with their depression. Findings from this study provide a greater understanding of the stigma associated with having a mental illness and its influence on attitudes toward mental health services.
depression; beliefs/attitudes; health service use; stigma; aging
Reducing mental health disparities among underserved populations, particularly African American elders, is an important public health priority. The authors describe the process and challenges of developing a community/academic research partnership to address these disparities.
The authors are using a Community-Based Participatory Research approach to gain access to underserved populations in need of depression treatment. The authors identify six stages: 1) Collaborating to Secure Funding; 2) Building a Communications Platform and Research Infrastructure; 3) Fostering Enduring Relationships; 4) Assessing Needs/Educating about Research Process; 5) Initiating Specific Collaborative Projects (meeting mutual needs/interests); and 6) Maintaining a Sustainable and Productive Partnership. Data from a needs assessment developed collaboratively by researchers and community agencies facilitated agreement on mutual research goals, while strengthening the partnership.
A community/academic-based partnership with a solid research infrastructure has been established and maintained for 3 years. Using the results of a needs assessment, the working partnership prioritized and launched several projects. Through interviews and questionnaires, community partners identified best practices for researchers working in the community. Future research and interventional projects have been developed, including plans for sustainability that will eventually shift more responsibility from the academic institution to the community agencies.
To reach underserved populations by developing and implementing models of more effective mental health treatment, it is vital to engage community agencies offering services to this population. A successful partnership requires “cultural humility,” collaborative efforts, and the development of flexible protocols to accommodate diverse communities.
Community partnerships; depression; community-based participatory research
This study compared African Americans’ and Caucasians’ willingness to participate in an indicated intervention to prevent depression with problem-solving therapy. It also examined participants’ problem-solving skills. Hypotheses stated that there would be no racial differences in consent rates and that social problem-solving coping skills would be lower among African Americans than Caucasians.
Proportions of African Americans and Caucasians who consented were compared, as were Social Problem Solving Inventory scores between the groups.
Of 2,788 individuals approached, 82 (4%) of 1,970 Caucasians and 46 (6%) of 818 African Americans signed consent, and the difference was not significant (p=.09). Racial differences were observed in neither Social Problem Solving Inventory scores nor in the relationship between problem-solving skills and depressive symptoms.
African Americans with depression demonstrated a willingness to participate in an indicated trial of depression prevention. Furthermore, both groups would appear to benefit from the problem-solving process.
This study examined the relationship between internalized and public stigma on treatment-related attitudes and behaviors in a community sample of 449 African American and white adults aged 18 years and older. Telephone surveys were administered to assess level of depressive symptoms, demographic characteristics, stigma, and treatment-related attitudes and behaviors. Multiple regression analysis indicated that internalized stigma mediated the relationship between public stigma and attitudes toward mental health treatment. Within group analyses indicated that the mediating effect of internalized stigma was significant for whites only. Among African Americans, internalized stigma did not mediate public stigma; it was directly related to attitudes toward mental health treatment. The internalization of stigma is key in the development of negative attitudes toward mental health treatment, and future research should focus on this aspect of stigma in both individual and community-based efforts to reduce stigma.
This study tested the hypothesis that women exposed to childhood abuse or neglect would have an increased likelihood of reporting hot flashes and night sweats during the menopausal transition.
This hypothesis was evaluated in 332 white and African American women participating in the Study of Women’s Health Across the Nation Mental Health Study, a prospective investigation of women transitioning through menopause. Childhood abuse and neglect were measured once with the Child Trauma Questionnaire. Vasomotor symptoms (any/none hot flashes, night sweats) were reported annually over 8 years. Associations between maltreatment and vasomotor symptoms were estimated with generalized estimating equations.
Childhood abuse or neglect was associated with increased reporting of hot flashes (odds ratio = 1.73, 95% CI: 1.23–2.43) and night sweats (odds ratio = 1.75, 95% CI: 1.26–2.43) in age-adjusted models. Results persisted in multivariable models and across several types of abuse and neglect.
The experience of childhood abuse and neglect is associated with increased vasomotor symptom reporting in adulthood. The sequelae of childhood abuse and neglect may persist well into adulthood to influence the occurrence of vasomotor symptoms at midlife.
Menopause; Vasomotor symptoms; Hot flashes; Child abuse; Neglect; Maltreatment
Reaching disadvantaged adults who need mental health care is challenging, partly because of mistrust of institutions, cultural insensitivity, and stigma. Researchers from Western Psychiatric Institute and Clinic and leaders of 11 non–mental health community organizations formed a partnership to improve depression care, especially for elders and individuals from difficult-to-reach racial and ethnic minority groups. The overarching goal is to reduce disparities by providing and improving care. This column describes challenges overcome in working with a heterogeneous group of agencies to address issues of mental illness, stigma, inadequate staff training, and privacy—challenges that influenced the direction of research and ensuing projects.
The authors detail the public health need for depression prevention research and the decisions made in designing an experiment testing problem solving therapy as “indicated” preventive intervention for high-risk older adults with subsyndromal depression. Special attention is given to the recruitment of African Americans because of well-documented inequalities in mental health services and depression treatment outcomes between races.
A total of 306 subjects (half white, half African American) with scores of 16 or higher on the Center for Epidemiological Studies of Depression Scale, but with no history of major depressive disorder in the past 12 months, are being recruited and randomly assigned to either problem solving therapy-primary care or to a dietary education control condition. Time to, and rate of, incident episodes of major depressive disorder are to be modeled using survival analysis. Level of depressive symptoms will be analyzed via a mixed models approach.
Twenty-two subjects have been recruited into the study, and to date eight have completed the randomly assigned intervention and postintervention assessment. Four of 22 have exited after developing major depressive episodes. None have complained about study procedures or demands. Implementation in a variety of community settings is going well.
The data collected to date support the feasibility of translating from epidemiology to RCT design and implementation of empirical depression prevention research in later life.
Depression prevention; indicated preventive intervention; elderly; African American; translation
Vesicle transport in cultured chick motoneurons was studied over a period of 3 days using motion enhanced differential interference contrast (MEDIC) microscopy, an improved version of video-enhanced DIC. After 3 days in vitro (DIV), the average vesicle velocity was about 30% less than after 1 DIV. In observations at 1, 2 and 3 DIV, larger vesicles moved more slowly than small vesicles, and retrograde vesicles were larger than anterograde vesicles. The number of retrograde vesicles increased relative to anterograde vesicles after 3 DIV, but this fact alone could not explain the decrease in velocity, since the slowing of vesicle transport in maturing motoneurons was observed independently for both anterograde and retrograde vesicles. In order to better understand the slowing trend, the distance vs. time trajectories of individual vesicles were examined at a frame rate of 8.3/s. Qualitatively, these trajectories consisted of short (1–2 s) segments of constant velocity, and the changes in velocity between segments were abrupt (<0.2 s). The trajectories were therefore fit to a series of connected straight lines. Surprisingly, the slopes of theses lines, i.e. the vesicle velocities, were often found to be multiples of ~0.6 µm/s. The velocity histogram showed multiple peaks, which, when fit with Gaussians using a least squares minimization, yielded an average spacing of 0.57 µm/s (taken as the slope of a fit to peak position vs. peak number, R2 = 0.994). We propose that the abrupt velocity changes occur when 1 or 2 motors suddenly begin or cease actively participating in vesicle transport. Under this hypothesis, the decrease in average vesicle velocity observed for maturing motoneurons is due to a decrease in the average number of active motors per vesicle.
Theme B (Cellular and Molecular Biology) Topics—“Cytoskeleton transport and membrane targeting” and “Staining, tracing, and imaging techniques”; Cellular and Molecular Biology of Nervous Systems; Processive molecular motors; cooperative fast axonal transport; anterograde neuron traffic; retrograde vesicle velocity; video enhanced differential interference contrast microscopy (VE-DIC); in vitro neuronal aging
The applicability and clinical utility of Leventhal's model of illness cognition is evaluated in depressed primary care patients. The intercorrelations of illness beliefs and the mediational effects of coping behavior on these beliefs are evaluated. Moderating effects of coping behaviors are explored.
Baseline evaluations of demographic information, depression diagnoses, depressive symptom severity, self-reported psychosocial and physical functioning, medical comorbidity, illness beliefs, and depression coping strategies were obtained from 191 primary care patients receiving antidepressant medication for the treatment of depression.
Patients' beliefs about depressive symptoms, causes, duration, controllability and consequences of these symptoms are described. Leventhal's mediational model was partially supported for the outcome of psychosocial functioning. Coping behavior did not mediate the relationship between illness beliefs and physical functioning. The relationship between participants' beliefs about the cause, controllability and duration of depressive symptoms were mediated by the use of behavioral disengagement, venting, or self-blame as a strategy to cope with depression. In addition, use of acceptance, religious coping, or behavioral disengagement moderated the relationship between beliefs about the cause of depression (i.e., environment or chance, medical illness) and psychosocial functioning.
Illness models for depression are important determinants of functioning in depressed primary care patients. These beliefs and coping behaviors are potentially modifiable and could be the target of interventions to decrease functional impairment in depressed patients.
depression; illness perceptions; primary care; coping
The unusual presentation of our two cases posed a diagnostic dilemma between a chronic expanding haematoma and soft tissue sarcoma even after all investigations and biopsy reports were complete. Salient points to differentiate between the two are discussed along with literature review.
We used a cross-sectional survey to compare the views of African-American and white adult primary care patients (N = 76) regarding the importance of various aspects of depression care. Patients were asked to rate the importance of 126 aspects of depression care (derived from attitudinal domains identified in focus groups) on a 5-point Likert scale. The 30 most important items came from 9 domains: 1) health professionals' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, 7) financial access, 8) life experiences, and 9) social support. African-American and white patients rated most aspects of depression care as similarly important, except that the odds of rating spirituality as extremely important for depression care were 3 times higher for African Americans than the odds for whites.
depression; spirituality; patient attitudes; African Americans