Carl C. Bell

Youth violence and gang involvement account for one of the most pressing public health and safety issues facing our country, and unless intervention efforts are redirected to include preventive rather than punitive strategies, the danger is not likely to diminish, Harvard Law School professor Charles J. Ogletree told a House of Representatives panel.

In a 2008 hearing on gang violence titled, “What's Effective? What's Not?,” Mr. Ogletree, who is also the founding director of the Charles Hamilton Houston Institute for Race & Justice in Boston, testified before the Subcommittee on Crime, Terrorism and Homeland Security that “public dollars spent on education and prevention are far more effective in stemming violence and discouraging gang affiliation than broadening prosecutorial powers or stiffening criminal penalties for young people accused of gang-related crimes.”

Not only do the “get tough” approaches that focus on prosecution and incarceration show little evidence of deterring gang activity, “tactics focused on increasing prosecutions, expanding the definition of gang membership, and lengthening prison sentences will likely strengthen, not reduce, gang affiliations by isolating children and teenagers with antisocial peers and by removing them from healthier social environments and opportunities to participate in more positive outlets.”

National statistics on youth gang activity back this up. Despite the increase in “anti-gang” legislation at the state and federal level over the past decade, the prevalence rates of youth gang activity remain significantly elevated, compared with recorded lows in the early 2000s, according to statistics from the U.S. Department of Justice 2008 National Youth Gang Survey.

In 2008, an estimated 32.4% of all cities, suburban areas, towns, and rural counties experienced gang problems, which is a 15% increase from 2002. Similarly, the approximate number of gangs and gang members estimated to be active in the United States increased by 28% and 6%, respectively, from 2002 to 2008.

Furthermore, more than one-quarter of the nation's public school students attend schools where gangs are present, according to the results of a national teen survey conducted by the National Center on Addiction and Substance Abuse at Columbia University in New York (Clinical Psychiatry News, September 2010, p. 1). The survey shows that gang activity is an important marker of drug activity. Nearly 60% of teens in schools with gangs – almost twice as many as in schools without gang activity – reported that drugs were used, kept, or sold on school grounds.

The increasing youth gang presence has coincided with an increase in gang-related criminal activity. According to Justice Department statistics, state, local, and federal law enforcement in 2004-2008 reported a 13% increase in gang activity.

In a recently published study investigating the psychological processes associated with gang membership, investigators observed that core and peripheral gang members committed more minor and violent offenses, were more antiauthority, and were more delinquent than were non–gang members overall (Aggr. Behav. 2010 Aug. 17 [doi:10.1002/ab.20360]).

Additionally, the findings of several studies have demonstrated that gang members are responsible for a large proportion of all violent offenses committed during the adolescent years, although this is difficult to confirm because of the “widespread limitations of officially recorded data on gang crime,” according to the U.S. Department of Justice National Gang Center.

Without question, the best interest of the public would be served by preventing youth gang involvement, but doing so cannot be achieved through the juvenile justice system alone, according to Robert D. Macy, Ph.D., executive director of the Boston Children's Foundation and founder of the Boston Center for Trauma Psychology.

“Violent behaviors and gang involvement are maladaptive coping and survival strategies. Reducing violence and gang involvement, thus, cannot be achieved only through arrest and incarceration as primary treatments,” he said. Rather, reducing the attachment to violence as a survival strategy requires “an evidence-based continuum of identification, assessment, and multidisciplinary treatment and psychoeducational programs for youth, youth offenders, and their caregivers.”

Critical to these efforts is an acceptance of the growing body of research that explains how traumatic life experiences alter brain development, especially in children, and an understanding of “the way in which the environment, experience, the brain and body, and the social context interact and affect each other,” Dr. Macy said. “These understandings, in turn, allow us to develop even more effective interventions to mediate the effects of trauma and thus, prevent violence among young people.”

To be effective, interventions for youth who are involved in gang activity “must address integrated intervention and prevention protocols at multiple levels,” Dr. Macy said. “We must use these multidisciplinary approaches and coordinate and intervene in family systems, with medical providers, the judiciary, the educators in public schools, public housing authorities, and others.”

An example of a multidisciplinary, integrated approach to reducing youth gang involvement and violence is the Youth & Police Initiative (YPI) developed by the North American Family Institute (NAFI) in which groups of community law enforcement agents are paired with at-risk teens from high-crime neighborhoods to discuss drug use, violence, gang activity, and youth-police interactions.

Through structured presentations, group learning, and problem-solving activities, the teens and the police officers explore their values and their attitudes about race, violence, respect, and law enforcement. Role-playing, de-escalation techniques, effective communication strategies, and team-building exercises are incorporated into the curriculum and aid in the development of new initiatives to enhance community policing.

Each training ends with a celebration attended by the teens and the police officers, as well as family members, political and religious leaders, and members of the community. Teen participants are offered follow-up leadership training by NAFI.

To date, the YPI initiative has been implemented in Boston, Baltimore, and White Plains and Yonkers, N.Y., and has been associated with significant increases in police officers' understanding of adolescent development and knowledge of urban socialization issues. The initiative also has improved the use of effective communication strategies between at-risk teens and police officers, according to Frank Straub, Ph.D., former commissioner of the White Plains Department of Public Safety, who credits that city's decrease in gang-related crime to the success of the program.

When it comes to the allocation of “gang-prevention dollars,” the most judicious spending should focus on “investments in proven programs that equip young people with life skills and alternative opportunities for engagement,” Mr. Ogletree stated in his testimony. “Additionally, programs and policies that treat problems related to conditions of poverty, educational failure, and isolation – all of which make gang membership attractive to youths living in communities of extreme disadvantage – have demonstrated their effectiveness and efficiency.” The most promising programs, he noted, are those that begin in preschool and are sustained over time through middle school and high school; provide a web of support by including families, schools, and communities; and focus on individual, social, and cultural development.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Youth violence and gang involvement account for one of the most pressing public health and safety issues facing our country, and unless intervention efforts are redirected to include preventive rather than punitive strategies, the danger is not likely to diminish, Harvard Law School professor Charles J. Ogletree told a House of Representatives panel.

In a 2008 hearing on gang violence titled, “What's Effective? What's Not?,” Mr. Ogletree, who is also the founding director of the Charles Hamilton Houston Institute for Race & Justice in Boston, testified before the Subcommittee on Crime, Terrorism and Homeland Security that “public dollars spent on education and prevention are far more effective in stemming violence and discouraging gang affiliation than broadening prosecutorial powers or stiffening criminal penalties for young people accused of gang-related crimes.”

Not only do the “get tough” approaches that focus on prosecution and incarceration show little evidence of deterring gang activity, “tactics focused on increasing prosecutions, expanding the definition of gang membership, and lengthening prison sentences will likely strengthen, not reduce, gang affiliations by isolating children and teenagers with antisocial peers and by removing them from healthier social environments and opportunities to participate in more positive outlets.”

National statistics on youth gang activity back this up. Despite the increase in “anti-gang” legislation at the state and federal level over the past decade, the prevalence rates of youth gang activity remain significantly elevated, compared with recorded lows in the early 2000s, according to statistics from the U.S. Department of Justice 2008 National Youth Gang Survey.

In 2008, an estimated 32.4% of all cities, suburban areas, towns, and rural counties experienced gang problems, which is a 15% increase from 2002. Similarly, the approximate number of gangs and gang members estimated to be active in the United States increased by 28% and 6%, respectively, from 2002 to 2008.

Furthermore, more than one-quarter of the nation's public school students attend schools where gangs are present, according to the results of a national teen survey conducted by the National Center on Addiction and Substance Abuse at Columbia University in New York (Clinical Psychiatry News, September 2010, p. 1). The survey shows that gang activity is an important marker of drug activity. Nearly 60% of teens in schools with gangs – almost twice as many as in schools without gang activity – reported that drugs were used, kept, or sold on school grounds.

The increasing youth gang presence has coincided with an increase in gang-related criminal activity. According to Justice Department statistics, state, local, and federal law enforcement in 2004-2008 reported a 13% increase in gang activity.

In a recently published study investigating the psychological processes associated with gang membership, investigators observed that core and peripheral gang members committed more minor and violent offenses, were more antiauthority, and were more delinquent than were non–gang members overall (Aggr. Behav. 2010 Aug. 17 [doi:10.1002/ab.20360]).

Additionally, the findings of several studies have demonstrated that gang members are responsible for a large proportion of all violent offenses committed during the adolescent years, although this is difficult to confirm because of the “widespread limitations of officially recorded data on gang crime,” according to the U.S. Department of Justice National Gang Center.

Without question, the best interest of the public would be served by preventing youth gang involvement, but doing so cannot be achieved through the juvenile justice system alone, according to Robert D. Macy, Ph.D., executive director of the Boston Children's Foundation and founder of the Boston Center for Trauma Psychology.

“Violent behaviors and gang involvement are maladaptive coping and survival strategies. Reducing violence and gang involvement, thus, cannot be achieved only through arrest and incarceration as primary treatments,” he said. Rather, reducing the attachment to violence as a survival strategy requires “an evidence-based continuum of identification, assessment, and multidisciplinary treatment and psychoeducational programs for youth, youth offenders, and their caregivers.”

Critical to these efforts is an acceptance of the growing body of research that explains how traumatic life experiences alter brain development, especially in children, and an understanding of “the way in which the environment, experience, the brain and body, and the social context interact and affect each other,” Dr. Macy said. “These understandings, in turn, allow us to develop even more effective interventions to mediate the effects of trauma and thus, prevent violence among young people.”

To be effective, interventions for youth who are involved in gang activity “must address integrated intervention and prevention protocols at multiple levels,” Dr. Macy said. “We must use these multidisciplinary approaches and coordinate and intervene in family systems, with medical providers, the judiciary, the educators in public schools, public housing authorities, and others.”

An example of a multidisciplinary, integrated approach to reducing youth gang involvement and violence is the Youth & Police Initiative (YPI) developed by the North American Family Institute (NAFI) in which groups of community law enforcement agents are paired with at-risk teens from high-crime neighborhoods to discuss drug use, violence, gang activity, and youth-police interactions.

Through structured presentations, group learning, and problem-solving activities, the teens and the police officers explore their values and their attitudes about race, violence, respect, and law enforcement. Role-playing, de-escalation techniques, effective communication strategies, and team-building exercises are incorporated into the curriculum and aid in the development of new initiatives to enhance community policing.

Each training ends with a celebration attended by the teens and the police officers, as well as family members, political and religious leaders, and members of the community. Teen participants are offered follow-up leadership training by NAFI.

To date, the YPI initiative has been implemented in Boston, Baltimore, and White Plains and Yonkers, N.Y., and has been associated with significant increases in police officers' understanding of adolescent development and knowledge of urban socialization issues. The initiative also has improved the use of effective communication strategies between at-risk teens and police officers, according to Frank Straub, Ph.D., former commissioner of the White Plains Department of Public Safety, who credits that city's decrease in gang-related crime to the success of the program.

When it comes to the allocation of “gang-prevention dollars,” the most judicious spending should focus on “investments in proven programs that equip young people with life skills and alternative opportunities for engagement,” Mr. Ogletree stated in his testimony. “Additionally, programs and policies that treat problems related to conditions of poverty, educational failure, and isolation – all of which make gang membership attractive to youths living in communities of extreme disadvantage – have demonstrated their effectiveness and efficiency.” The most promising programs, he noted, are those that begin in preschool and are sustained over time through middle school and high school; provide a web of support by including families, schools, and communities; and focus on individual, social, and cultural development.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Youth violence and gang involvement account for one of the most pressing public health and safety issues facing our country, and unless intervention efforts are redirected to include preventive rather than punitive strategies, the danger is not likely to diminish, Harvard Law School professor Charles J. Ogletree told a House of Representatives panel.

In a 2008 hearing on gang violence titled, “What's Effective? What's Not?,” Mr. Ogletree, who is also the founding director of the Charles Hamilton Houston Institute for Race & Justice in Boston, testified before the Subcommittee on Crime, Terrorism and Homeland Security that “public dollars spent on education and prevention are far more effective in stemming violence and discouraging gang affiliation than broadening prosecutorial powers or stiffening criminal penalties for young people accused of gang-related crimes.”

Not only do the “get tough” approaches that focus on prosecution and incarceration show little evidence of deterring gang activity, “tactics focused on increasing prosecutions, expanding the definition of gang membership, and lengthening prison sentences will likely strengthen, not reduce, gang affiliations by isolating children and teenagers with antisocial peers and by removing them from healthier social environments and opportunities to participate in more positive outlets.”

National statistics on youth gang activity back this up. Despite the increase in “anti-gang” legislation at the state and federal level over the past decade, the prevalence rates of youth gang activity remain significantly elevated, compared with recorded lows in the early 2000s, according to statistics from the U.S. Department of Justice 2008 National Youth Gang Survey.

In 2008, an estimated 32.4% of all cities, suburban areas, towns, and rural counties experienced gang problems, which is a 15% increase from 2002. Similarly, the approximate number of gangs and gang members estimated to be active in the United States increased by 28% and 6%, respectively, from 2002 to 2008.

Furthermore, more than one-quarter of the nation's public school students attend schools where gangs are present, according to the results of a national teen survey conducted by the National Center on Addiction and Substance Abuse at Columbia University in New York (Clinical Psychiatry News, September 2010, p. 1). The survey shows that gang activity is an important marker of drug activity. Nearly 60% of teens in schools with gangs – almost twice as many as in schools without gang activity – reported that drugs were used, kept, or sold on school grounds.

The increasing youth gang presence has coincided with an increase in gang-related criminal activity. According to Justice Department statistics, state, local, and federal law enforcement in 2004-2008 reported a 13% increase in gang activity.

In a recently published study investigating the psychological processes associated with gang membership, investigators observed that core and peripheral gang members committed more minor and violent offenses, were more antiauthority, and were more delinquent than were non–gang members overall (Aggr. Behav. 2010 Aug. 17 [doi:10.1002/ab.20360]).

Additionally, the findings of several studies have demonstrated that gang members are responsible for a large proportion of all violent offenses committed during the adolescent years, although this is difficult to confirm because of the “widespread limitations of officially recorded data on gang crime,” according to the U.S. Department of Justice National Gang Center.

Without question, the best interest of the public would be served by preventing youth gang involvement, but doing so cannot be achieved through the juvenile justice system alone, according to Robert D. Macy, Ph.D., executive director of the Boston Children's Foundation and founder of the Boston Center for Trauma Psychology.

“Violent behaviors and gang involvement are maladaptive coping and survival strategies. Reducing violence and gang involvement, thus, cannot be achieved only through arrest and incarceration as primary treatments,” he said. Rather, reducing the attachment to violence as a survival strategy requires “an evidence-based continuum of identification, assessment, and multidisciplinary treatment and psychoeducational programs for youth, youth offenders, and their caregivers.”

Critical to these efforts is an acceptance of the growing body of research that explains how traumatic life experiences alter brain development, especially in children, and an understanding of “the way in which the environment, experience, the brain and body, and the social context interact and affect each other,” Dr. Macy said. “These understandings, in turn, allow us to develop even more effective interventions to mediate the effects of trauma and thus, prevent violence among young people.”

To be effective, interventions for youth who are involved in gang activity “must address integrated intervention and prevention protocols at multiple levels,” Dr. Macy said. “We must use these multidisciplinary approaches and coordinate and intervene in family systems, with medical providers, the judiciary, the educators in public schools, public housing authorities, and others.”

An example of a multidisciplinary, integrated approach to reducing youth gang involvement and violence is the Youth & Police Initiative (YPI) developed by the North American Family Institute (NAFI) in which groups of community law enforcement agents are paired with at-risk teens from high-crime neighborhoods to discuss drug use, violence, gang activity, and youth-police interactions.

Through structured presentations, group learning, and problem-solving activities, the teens and the police officers explore their values and their attitudes about race, violence, respect, and law enforcement. Role-playing, de-escalation techniques, effective communication strategies, and team-building exercises are incorporated into the curriculum and aid in the development of new initiatives to enhance community policing.

Each training ends with a celebration attended by the teens and the police officers, as well as family members, political and religious leaders, and members of the community. Teen participants are offered follow-up leadership training by NAFI.

To date, the YPI initiative has been implemented in Boston, Baltimore, and White Plains and Yonkers, N.Y., and has been associated with significant increases in police officers' understanding of adolescent development and knowledge of urban socialization issues. The initiative also has improved the use of effective communication strategies between at-risk teens and police officers, according to Frank Straub, Ph.D., former commissioner of the White Plains Department of Public Safety, who credits that city's decrease in gang-related crime to the success of the program.

When it comes to the allocation of “gang-prevention dollars,” the most judicious spending should focus on “investments in proven programs that equip young people with life skills and alternative opportunities for engagement,” Mr. Ogletree stated in his testimony. “Additionally, programs and policies that treat problems related to conditions of poverty, educational failure, and isolation – all of which make gang membership attractive to youths living in communities of extreme disadvantage – have demonstrated their effectiveness and efficiency.” The most promising programs, he noted, are those that begin in preschool and are sustained over time through middle school and high school; provide a web of support by including families, schools, and communities; and focus on individual, social, and cultural development.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

The irrationality of the age-old, artificial dichotomy between physical and mental health is painfully obvious in the longstanding failure to address the association between diabetes and major depression.

“We have known for years that these conditions overlap, yet their combination continues to lead to worse physical and psychiatric outcomes,” according to David Osborn, Ph.D., senior lecturer of epidemiology and community psychiatry at University College London.

The Centers for Disease Control and Prevention estimates that nearly 24 million people in the United States alone have diabetes. Considering this increasing prevalence of diabetes and recent evidence indicating a significantly poorer prognosis for diabetic adults with comorbid depression, “the need to develop and evaluate coherent services that address both the mental and physical needs of these patients cannot be overstated,” he said.

Patients with type 2 diabetes mellitus are at least twice as likely as their nondiabetic peers to experience depressive symptoms, and the aggregated lifetime prevalence of major depression in this population might be as high as 27%, according to a 2001 meta-analysis (Diabetes Care 2001;24:1069–78). In particular, individuals with poorly controlled diabetes are more likely to have depression, possibly because of the association between depression and problems with medication and diet adherence (J. Diabetes Complications 2005;19:113–22).

Several studies have linked depression with an increased risk of developing diabetes-related complications, as well as increased mortality. In a recent prospective investigation into the association between depression and all-cause and cause-specific mortality in patients with diabetes, Dr. Elizabeth H.B. Lin of the Group Health Research Institute in Seattle, and colleagues used the Patient Health Questionnaire (PHQ-9) to assess depression at baseline in a cohort of 4,184 patients with type 2 diabetes who received care at one of nine Group Health primary care clinics between 2000 and 2002.

Annually through 2007, the researchers reviewed the patients' medical records and the death registry files of Washington state to ascertain the causes of death. After adjusting for demographic characteristics for the 428 patients who died, they found that major depression was significantly associated with all-cause mortality, cardiovascular mortality, and noncardiovascular, noncancer mortality. “Patients with diabetes and coexisting depression face substantially elevated mortality risks beyond cardiovascular deaths,” they reported (Ann. Fam. Med. 2009;5:414–21).

In a second study, Dr. Lin and her colleagues also tracked the rates of microvascular and macrovascular complications by conducting follow-up interviews between 2005 and 2007 with the surviving study participants. For this analysis, microvascular complications included blindness, end-state kidney disease, amputations, and kidney failure; and macrovascular complications included myocardial infarction, stroke, and cardiovascular procedures. The authors determined that, over the 5-year follow-up period, participants with major depression had a 36% increased risk of developing microvascular complications and a 25% increased risk of developing macrovascular complications, compared with patients without major depression. Reducing the risk of diabetes complications requires “better interventions that not only treat the diabetes but address any accompanying depression as well,” the authors concluded (Diabetes Care 2010;33:264–9).

Such interventions exist, and they are effective. In 2007, Dr. Hillary Bogner and colleagues in the University of Pennsylvania, Philadelphia, conducted a randomized, controlled trial of a depression treatment program for older adults with diabetes who were based in primary care. The researchers used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), which they supplemented with a search of the National Death Index.

Patients with diabetes in the study who screened positive for depression were randomized to usual care or to a depression management intervention, which involved assignment to a depression care manager who worked with the patient's primary care provider to recommend treatment, monitor, and assist with adherence. Patients in the intervention group were half as likely as patients in the usual care group to die during the 5-year follow-up period (Diabetes Care 2007;30:3005–10).

In a more recent study, Dr. Bogner and her colleagues determined that integrating treatment for type 2 diabetes and depression improved medication adherence, glycemic control, and depression outcomes in older African American men–a group that is at high risk for poor outcomes. Of the 58 African American male patients aged 50–80 years who participated in the pilot trial, those who were randomized to integrated depression treatment had significantly greater adherence to their oral hypoglycemic and antidepressant medications at 6 weeks than did the usual care group. (Diabetes Educ. 2010;36:284–92).

Dr. Bogner said in an interview that without question, “these findings support the integration of depression screening and treatment with diabetes management in primary care, especially in high-risk populations.”

Dr. Diana Echeverry and colleagues at Charles Drew University in Los Angeles reached a similar conclusion. They recently conducted a randomized, placebo-controlled trial to determine the impact that screening and pharmacologic treatment of depression would have on diabetes-related outcomes in low-income minorities.

Prospective study participants included low-income Hispanic and African American adults with elevated HbA_1c levels. They underwent a low-intensity (two-question) primary care screen for depression, which, if positive, was followed by a computerized diagnostic interview survey for the diagnosis of depression. Patients with depression were then randomized to receive the antidepressant sertraline or placebo. At 6 months, the sertraline group demonstrated greater improvements in HbA_1c levels and systolic blood pressure, compared with the control group, and both groups had improved depression scores–possibly because of the increased contact with a “sympathetic questioner,” according to the authors. They noted that the screening questions had positive prediction for depression ranging from 67% to 84%, indicating the value of a low-intensity screen and computerized assessment in the primary care setting (Diabetes Care 2009;32:2156–60).

Combined behavioral interventions also can play an important role in the management of depression in adult patients with diabetes. Mary de Groot, Ph.D., of Indiana University, Indianapolis, and her colleagues recently reported the results of a study designed to test the effectiveness of a combination behavioral approach to the treatment of depression in adult patients with type 2 diabetes living in the rural Appalachian region. The 12-week interdisciplinary intervention, called Program ACTIVE, combined concurrent cognitive behavioral therapy and community-based exercise. The study enrolled 50 adults with diabetes who had screened positive for depression at baseline. Immediately after the intervention and at 3 months after the intervention, the mean Beck Depression Inventory scores of the participants improved significantly relative to baseline, and more than half of the patients no longer met the criteria for major depressive disorder, the authors reported.

With respect to diabetes outcomes, significant improvements were observed in blood glucose levels and low-density lipoprotein cholesterol levels relative to baseline, both immediately after and 3 months after the intervention, the authors wrote (Diabetes Spectrum 2010;23:18–25).

Interventions such as Program ACTIVE can be successful in improving depression and diabetes outcomes despite geographic and financial obstacles “if they are flexible in their approach and make use of community resources to facilitate participant self-care,” according to Dr. de Groot. “In doing so, there is great opportunity to address the significant costs associated with comorbid depression and diabetes.”

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

The irrationality of the age-old, artificial dichotomy between physical and mental health is painfully obvious in the longstanding failure to address the association between diabetes and major depression.

“We have known for years that these conditions overlap, yet their combination continues to lead to worse physical and psychiatric outcomes,” according to David Osborn, Ph.D., senior lecturer of epidemiology and community psychiatry at University College London.

The Centers for Disease Control and Prevention estimates that nearly 24 million people in the United States alone have diabetes. Considering this increasing prevalence of diabetes and recent evidence indicating a significantly poorer prognosis for diabetic adults with comorbid depression, “the need to develop and evaluate coherent services that address both the mental and physical needs of these patients cannot be overstated,” he said.

Patients with type 2 diabetes mellitus are at least twice as likely as their nondiabetic peers to experience depressive symptoms, and the aggregated lifetime prevalence of major depression in this population might be as high as 27%, according to a 2001 meta-analysis (Diabetes Care 2001;24:1069–78). In particular, individuals with poorly controlled diabetes are more likely to have depression, possibly because of the association between depression and problems with medication and diet adherence (J. Diabetes Complications 2005;19:113–22).

Several studies have linked depression with an increased risk of developing diabetes-related complications, as well as increased mortality. In a recent prospective investigation into the association between depression and all-cause and cause-specific mortality in patients with diabetes, Dr. Elizabeth H.B. Lin of the Group Health Research Institute in Seattle, and colleagues used the Patient Health Questionnaire (PHQ-9) to assess depression at baseline in a cohort of 4,184 patients with type 2 diabetes who received care at one of nine Group Health primary care clinics between 2000 and 2002.

Annually through 2007, the researchers reviewed the patients' medical records and the death registry files of Washington state to ascertain the causes of death. After adjusting for demographic characteristics for the 428 patients who died, they found that major depression was significantly associated with all-cause mortality, cardiovascular mortality, and noncardiovascular, noncancer mortality. “Patients with diabetes and coexisting depression face substantially elevated mortality risks beyond cardiovascular deaths,” they reported (Ann. Fam. Med. 2009;5:414–21).

In a second study, Dr. Lin and her colleagues also tracked the rates of microvascular and macrovascular complications by conducting follow-up interviews between 2005 and 2007 with the surviving study participants. For this analysis, microvascular complications included blindness, end-state kidney disease, amputations, and kidney failure; and macrovascular complications included myocardial infarction, stroke, and cardiovascular procedures. The authors determined that, over the 5-year follow-up period, participants with major depression had a 36% increased risk of developing microvascular complications and a 25% increased risk of developing macrovascular complications, compared with patients without major depression. Reducing the risk of diabetes complications requires “better interventions that not only treat the diabetes but address any accompanying depression as well,” the authors concluded (Diabetes Care 2010;33:264–9).

Such interventions exist, and they are effective. In 2007, Dr. Hillary Bogner and colleagues in the University of Pennsylvania, Philadelphia, conducted a randomized, controlled trial of a depression treatment program for older adults with diabetes who were based in primary care. The researchers used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), which they supplemented with a search of the National Death Index.

Patients with diabetes in the study who screened positive for depression were randomized to usual care or to a depression management intervention, which involved assignment to a depression care manager who worked with the patient's primary care provider to recommend treatment, monitor, and assist with adherence. Patients in the intervention group were half as likely as patients in the usual care group to die during the 5-year follow-up period (Diabetes Care 2007;30:3005–10).

In a more recent study, Dr. Bogner and her colleagues determined that integrating treatment for type 2 diabetes and depression improved medication adherence, glycemic control, and depression outcomes in older African American men–a group that is at high risk for poor outcomes. Of the 58 African American male patients aged 50–80 years who participated in the pilot trial, those who were randomized to integrated depression treatment had significantly greater adherence to their oral hypoglycemic and antidepressant medications at 6 weeks than did the usual care group. (Diabetes Educ. 2010;36:284–92).

Dr. Bogner said in an interview that without question, “these findings support the integration of depression screening and treatment with diabetes management in primary care, especially in high-risk populations.”

Dr. Diana Echeverry and colleagues at Charles Drew University in Los Angeles reached a similar conclusion. They recently conducted a randomized, placebo-controlled trial to determine the impact that screening and pharmacologic treatment of depression would have on diabetes-related outcomes in low-income minorities.

Prospective study participants included low-income Hispanic and African American adults with elevated HbA_1c levels. They underwent a low-intensity (two-question) primary care screen for depression, which, if positive, was followed by a computerized diagnostic interview survey for the diagnosis of depression. Patients with depression were then randomized to receive the antidepressant sertraline or placebo. At 6 months, the sertraline group demonstrated greater improvements in HbA_1c levels and systolic blood pressure, compared with the control group, and both groups had improved depression scores–possibly because of the increased contact with a “sympathetic questioner,” according to the authors. They noted that the screening questions had positive prediction for depression ranging from 67% to 84%, indicating the value of a low-intensity screen and computerized assessment in the primary care setting (Diabetes Care 2009;32:2156–60).

Combined behavioral interventions also can play an important role in the management of depression in adult patients with diabetes. Mary de Groot, Ph.D., of Indiana University, Indianapolis, and her colleagues recently reported the results of a study designed to test the effectiveness of a combination behavioral approach to the treatment of depression in adult patients with type 2 diabetes living in the rural Appalachian region. The 12-week interdisciplinary intervention, called Program ACTIVE, combined concurrent cognitive behavioral therapy and community-based exercise. The study enrolled 50 adults with diabetes who had screened positive for depression at baseline. Immediately after the intervention and at 3 months after the intervention, the mean Beck Depression Inventory scores of the participants improved significantly relative to baseline, and more than half of the patients no longer met the criteria for major depressive disorder, the authors reported.

With respect to diabetes outcomes, significant improvements were observed in blood glucose levels and low-density lipoprotein cholesterol levels relative to baseline, both immediately after and 3 months after the intervention, the authors wrote (Diabetes Spectrum 2010;23:18–25).

Interventions such as Program ACTIVE can be successful in improving depression and diabetes outcomes despite geographic and financial obstacles “if they are flexible in their approach and make use of community resources to facilitate participant self-care,” according to Dr. de Groot. “In doing so, there is great opportunity to address the significant costs associated with comorbid depression and diabetes.”

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

The irrationality of the age-old, artificial dichotomy between physical and mental health is painfully obvious in the longstanding failure to address the association between diabetes and major depression.

“We have known for years that these conditions overlap, yet their combination continues to lead to worse physical and psychiatric outcomes,” according to David Osborn, Ph.D., senior lecturer of epidemiology and community psychiatry at University College London.

The Centers for Disease Control and Prevention estimates that nearly 24 million people in the United States alone have diabetes. Considering this increasing prevalence of diabetes and recent evidence indicating a significantly poorer prognosis for diabetic adults with comorbid depression, “the need to develop and evaluate coherent services that address both the mental and physical needs of these patients cannot be overstated,” he said.

Patients with type 2 diabetes mellitus are at least twice as likely as their nondiabetic peers to experience depressive symptoms, and the aggregated lifetime prevalence of major depression in this population might be as high as 27%, according to a 2001 meta-analysis (Diabetes Care 2001;24:1069–78). In particular, individuals with poorly controlled diabetes are more likely to have depression, possibly because of the association between depression and problems with medication and diet adherence (J. Diabetes Complications 2005;19:113–22).

Several studies have linked depression with an increased risk of developing diabetes-related complications, as well as increased mortality. In a recent prospective investigation into the association between depression and all-cause and cause-specific mortality in patients with diabetes, Dr. Elizabeth H.B. Lin of the Group Health Research Institute in Seattle, and colleagues used the Patient Health Questionnaire (PHQ-9) to assess depression at baseline in a cohort of 4,184 patients with type 2 diabetes who received care at one of nine Group Health primary care clinics between 2000 and 2002.

Annually through 2007, the researchers reviewed the patients' medical records and the death registry files of Washington state to ascertain the causes of death. After adjusting for demographic characteristics for the 428 patients who died, they found that major depression was significantly associated with all-cause mortality, cardiovascular mortality, and noncardiovascular, noncancer mortality. “Patients with diabetes and coexisting depression face substantially elevated mortality risks beyond cardiovascular deaths,” they reported (Ann. Fam. Med. 2009;5:414–21).

In a second study, Dr. Lin and her colleagues also tracked the rates of microvascular and macrovascular complications by conducting follow-up interviews between 2005 and 2007 with the surviving study participants. For this analysis, microvascular complications included blindness, end-state kidney disease, amputations, and kidney failure; and macrovascular complications included myocardial infarction, stroke, and cardiovascular procedures. The authors determined that, over the 5-year follow-up period, participants with major depression had a 36% increased risk of developing microvascular complications and a 25% increased risk of developing macrovascular complications, compared with patients without major depression. Reducing the risk of diabetes complications requires “better interventions that not only treat the diabetes but address any accompanying depression as well,” the authors concluded (Diabetes Care 2010;33:264–9).

Such interventions exist, and they are effective. In 2007, Dr. Hillary Bogner and colleagues in the University of Pennsylvania, Philadelphia, conducted a randomized, controlled trial of a depression treatment program for older adults with diabetes who were based in primary care. The researchers used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), which they supplemented with a search of the National Death Index.

Patients with diabetes in the study who screened positive for depression were randomized to usual care or to a depression management intervention, which involved assignment to a depression care manager who worked with the patient's primary care provider to recommend treatment, monitor, and assist with adherence. Patients in the intervention group were half as likely as patients in the usual care group to die during the 5-year follow-up period (Diabetes Care 2007;30:3005–10).

In a more recent study, Dr. Bogner and her colleagues determined that integrating treatment for type 2 diabetes and depression improved medication adherence, glycemic control, and depression outcomes in older African American men–a group that is at high risk for poor outcomes. Of the 58 African American male patients aged 50–80 years who participated in the pilot trial, those who were randomized to integrated depression treatment had significantly greater adherence to their oral hypoglycemic and antidepressant medications at 6 weeks than did the usual care group. (Diabetes Educ. 2010;36:284–92).

Dr. Bogner said in an interview that without question, “these findings support the integration of depression screening and treatment with diabetes management in primary care, especially in high-risk populations.”

Dr. Diana Echeverry and colleagues at Charles Drew University in Los Angeles reached a similar conclusion. They recently conducted a randomized, placebo-controlled trial to determine the impact that screening and pharmacologic treatment of depression would have on diabetes-related outcomes in low-income minorities.

Prospective study participants included low-income Hispanic and African American adults with elevated HbA_1c levels. They underwent a low-intensity (two-question) primary care screen for depression, which, if positive, was followed by a computerized diagnostic interview survey for the diagnosis of depression. Patients with depression were then randomized to receive the antidepressant sertraline or placebo. At 6 months, the sertraline group demonstrated greater improvements in HbA_1c levels and systolic blood pressure, compared with the control group, and both groups had improved depression scores–possibly because of the increased contact with a “sympathetic questioner,” according to the authors. They noted that the screening questions had positive prediction for depression ranging from 67% to 84%, indicating the value of a low-intensity screen and computerized assessment in the primary care setting (Diabetes Care 2009;32:2156–60).

Combined behavioral interventions also can play an important role in the management of depression in adult patients with diabetes. Mary de Groot, Ph.D., of Indiana University, Indianapolis, and her colleagues recently reported the results of a study designed to test the effectiveness of a combination behavioral approach to the treatment of depression in adult patients with type 2 diabetes living in the rural Appalachian region. The 12-week interdisciplinary intervention, called Program ACTIVE, combined concurrent cognitive behavioral therapy and community-based exercise. The study enrolled 50 adults with diabetes who had screened positive for depression at baseline. Immediately after the intervention and at 3 months after the intervention, the mean Beck Depression Inventory scores of the participants improved significantly relative to baseline, and more than half of the patients no longer met the criteria for major depressive disorder, the authors reported.

With respect to diabetes outcomes, significant improvements were observed in blood glucose levels and low-density lipoprotein cholesterol levels relative to baseline, both immediately after and 3 months after the intervention, the authors wrote (Diabetes Spectrum 2010;23:18–25).

Interventions such as Program ACTIVE can be successful in improving depression and diabetes outcomes despite geographic and financial obstacles “if they are flexible in their approach and make use of community resources to facilitate participant self-care,” according to Dr. de Groot. “In doing so, there is great opportunity to address the significant costs associated with comorbid depression and diabetes.”

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Creative engagement is to the aging brain as physical activity is to the aging body. Just as studies have shown older adults who maintain higher levels of muscle strength, flexibility, and aerobic capacity are healthier and better able to preserve their independent function longer than their more sedentary peers, an emerging body of literature suggests that those who engage in creative activities exhibit increased psychological well-being.

For example, findings from the federally funded Creativity and Aging study spearheaded by the late Dr. Gene D. Cohen and colleagues in the Center on Aging, Health, and Humanities at George Washington University, Washington, showed that participation in community-based cultural programs improved both the general health and mental health of older adults.

Specifically, the study recruited 300 healthy, ambulatory, older adults between the ages of 65 and 103 in New York, Washington, and San Francisco. Half of the participants were assigned to participate in professionally conducted arts programs, such as singing, creative writing, poetry, painting, or jewelry making, while the other half maintained usual activity.

Results from the Washington group showed that, after 2 years, the arts group reported better overall physical health, fewer doctor visits, fewer falls, and better scores on depression and loneliness scales. Additionally, the authors noted that participation in the community-based arts activities had a positive impact on the individuals' ability to maintain their independence by reducing the risk factors “that drive the need for long-term care” (Gerontologist 2006;46:726-34).

Other studies have produced similar findings. In 1999, Frederick Tims, Ph.D., professor and area chair of music therapy at Michigan State University, East Lansing, reported the results of the Music Making and Wellness Project in which the investigators compared the well-being of 61 older adults who were assigned to participate in group keyboard lessons with that of a control group of similar aged adults who did not participate. After the music intervention, the keyboard group showed significant decreases in anxiety, depression, and loneliness, and increasing levels of human growth hormone–which has been implicated in a range of age-related health conditions.

In 2004, investigators in the psychology and theatre departments at Elmhurst (Ill.) College, evaluated the impact that a short-term theater arts intervention had on the cognitive and affective functioning of older adults living in the community. A total of 124 participants aged 60–86 years were assigned to one of three group: theater arts, non–content specific visual arts, and no treatment. After 4 weeks, the adults in the theater arts group improved significantly more than the no-treatment control group in each of the four measures: word recall, memory, problem solving, and psychological well-being.

Adults in the visual arts group showed smaller improvements relative to the control group, according to the authors. Four months after the study, the theater group had maintained their performance improvements across all measures, they wrote. The authors concluded that theater training, even over a short time period, can help prevent cognitive decline associated with aging (J. Aging Health 2004;16:562-85).

Creative engagement also can improve the quality of life for adults with Alzheimer's disease and other age-related dementias. In an observational study published in 2005 in the American Journal of Alzheimer's Disease and Other Dementias, the well-being of 12 older adults with dementia improved while participating in an art program called Memories in the Making than they did during more-traditional adult day care activities.

Specifically, participants in the program, which encourages self-expression through the visual arts for adults in the early and middle stages of dementia, exhibited significantly more interest, sustained attention, pleasure, self-esteem, and normalcy during the intervention period (Am. J. Alzheimers Dis. Other Demen. 2005;20:220-7).

More recently, researchers from the University of Wisconsin's Center on Age and Community in Milwaukee reported that participation in a group storytelling program called TimeSlips, developed by the center's executive director Anne Basting, Ph.D., improved the alertness and level of engagement among individuals with dementia living in long-term care settings, compared with a control group of peers from nonparticipating facilities. The researchers also observed improved staff-resident interactions, social interactions, and social engagement in the participating centers (Gerontologist 2009;49:117-27).

Using the arts and creative engagement “gives us a way to focus on remaining strengths and even growth during a time that is perceived as an inevitable and total decline, which in turn brings meaning and hope to families and care providers alike,” Dr. Basting said in an interview.

The link between creative engagement and positive psychosocial outcomes in older adults can likely be attributed to multiple mechanisms. It is possible, according to Roberto Cabeza, Ph.D., professor of psychology and neuroscience in the Center for Cognitive Neuroscience at Duke University, Durham, N.C., that participating in activities that challenge the mind, such as artistic expression “stimulates the growth of new brain cells in the cerebral cortex.” Even as we age, he said, “the creation of new neuron networks continues.”

Susan H. McFadden, Ph.D., professor of psychology at the University of Wisconsin, Oshkosh, and coauthor with Dr. Basting of a paper titled “Healthy Aging Persons and Their Brains: Promoting Resilience Through Creative Engagement” published in February (Clin. Geriatr. Med. 2010;26:149-61), believes that one of the most fundamental mechanisms is the “sense of social connectedness” that comes from working together on projects related to the arts.

Other possible contributors are “the physical activity in some of these programs, the sense of optimism people feel about working together on something they all think is important, the positive emotions they experience, and a sense of mastery and hopefulness that comes from investing yourself in something important,” she said in an interview. “All of these have positive effects on the immune system, the endocrine system, and the nervous system.”

She said several organizations support creative engagement with well and frail older adults, and several well-known programs target this population. The University of Wisconsin Center on Age & Community Web site has an extensive list of products and resources, including free, downloadable white papers on this issue (www.aging.uwm.eduwww.aging.uwm.eduwww.creativeaging.org

Also, she said, the Society for the Arts in Healthcare is in the process of putting together a primer aimed at helping artists learn how to work with frail older adults; the Museum of Modern Art, New York, has an elegant book called “Meet Me: Making Art Accessible to People with Dementia” that seeks to help museums begin education programs for people with dementia; and a book by John Zeisel, Ph.D., addresses the arts as part of a full treatment plan that also includes assessment of the environment (“I'm Still Here” [New York: Avery, 2009]).

In her book, “Forget Memory: Creating Better Lives for People With Dementia” (Baltimore: Johns Hopkins University Press, 2009), Dr. Basting highlights a range of arts programs designed for the elderly.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Creative engagement is to the aging brain as physical activity is to the aging body. Just as studies have shown older adults who maintain higher levels of muscle strength, flexibility, and aerobic capacity are healthier and better able to preserve their independent function longer than their more sedentary peers, an emerging body of literature suggests that those who engage in creative activities exhibit increased psychological well-being.

For example, findings from the federally funded Creativity and Aging study spearheaded by the late Dr. Gene D. Cohen and colleagues in the Center on Aging, Health, and Humanities at George Washington University, Washington, showed that participation in community-based cultural programs improved both the general health and mental health of older adults.

Specifically, the study recruited 300 healthy, ambulatory, older adults between the ages of 65 and 103 in New York, Washington, and San Francisco. Half of the participants were assigned to participate in professionally conducted arts programs, such as singing, creative writing, poetry, painting, or jewelry making, while the other half maintained usual activity.

Results from the Washington group showed that, after 2 years, the arts group reported better overall physical health, fewer doctor visits, fewer falls, and better scores on depression and loneliness scales. Additionally, the authors noted that participation in the community-based arts activities had a positive impact on the individuals' ability to maintain their independence by reducing the risk factors “that drive the need for long-term care” (Gerontologist 2006;46:726-34).

Other studies have produced similar findings. In 1999, Frederick Tims, Ph.D., professor and area chair of music therapy at Michigan State University, East Lansing, reported the results of the Music Making and Wellness Project in which the investigators compared the well-being of 61 older adults who were assigned to participate in group keyboard lessons with that of a control group of similar aged adults who did not participate. After the music intervention, the keyboard group showed significant decreases in anxiety, depression, and loneliness, and increasing levels of human growth hormone–which has been implicated in a range of age-related health conditions.

In 2004, investigators in the psychology and theatre departments at Elmhurst (Ill.) College, evaluated the impact that a short-term theater arts intervention had on the cognitive and affective functioning of older adults living in the community. A total of 124 participants aged 60–86 years were assigned to one of three group: theater arts, non–content specific visual arts, and no treatment. After 4 weeks, the adults in the theater arts group improved significantly more than the no-treatment control group in each of the four measures: word recall, memory, problem solving, and psychological well-being.

Adults in the visual arts group showed smaller improvements relative to the control group, according to the authors. Four months after the study, the theater group had maintained their performance improvements across all measures, they wrote. The authors concluded that theater training, even over a short time period, can help prevent cognitive decline associated with aging (J. Aging Health 2004;16:562-85).

Creative engagement also can improve the quality of life for adults with Alzheimer's disease and other age-related dementias. In an observational study published in 2005 in the American Journal of Alzheimer's Disease and Other Dementias, the well-being of 12 older adults with dementia improved while participating in an art program called Memories in the Making than they did during more-traditional adult day care activities.

Specifically, participants in the program, which encourages self-expression through the visual arts for adults in the early and middle stages of dementia, exhibited significantly more interest, sustained attention, pleasure, self-esteem, and normalcy during the intervention period (Am. J. Alzheimers Dis. Other Demen. 2005;20:220-7).

More recently, researchers from the University of Wisconsin's Center on Age and Community in Milwaukee reported that participation in a group storytelling program called TimeSlips, developed by the center's executive director Anne Basting, Ph.D., improved the alertness and level of engagement among individuals with dementia living in long-term care settings, compared with a control group of peers from nonparticipating facilities. The researchers also observed improved staff-resident interactions, social interactions, and social engagement in the participating centers (Gerontologist 2009;49:117-27).

Using the arts and creative engagement “gives us a way to focus on remaining strengths and even growth during a time that is perceived as an inevitable and total decline, which in turn brings meaning and hope to families and care providers alike,” Dr. Basting said in an interview.

The link between creative engagement and positive psychosocial outcomes in older adults can likely be attributed to multiple mechanisms. It is possible, according to Roberto Cabeza, Ph.D., professor of psychology and neuroscience in the Center for Cognitive Neuroscience at Duke University, Durham, N.C., that participating in activities that challenge the mind, such as artistic expression “stimulates the growth of new brain cells in the cerebral cortex.” Even as we age, he said, “the creation of new neuron networks continues.”

Susan H. McFadden, Ph.D., professor of psychology at the University of Wisconsin, Oshkosh, and coauthor with Dr. Basting of a paper titled “Healthy Aging Persons and Their Brains: Promoting Resilience Through Creative Engagement” published in February (Clin. Geriatr. Med. 2010;26:149-61), believes that one of the most fundamental mechanisms is the “sense of social connectedness” that comes from working together on projects related to the arts.

Other possible contributors are “the physical activity in some of these programs, the sense of optimism people feel about working together on something they all think is important, the positive emotions they experience, and a sense of mastery and hopefulness that comes from investing yourself in something important,” she said in an interview. “All of these have positive effects on the immune system, the endocrine system, and the nervous system.”

She said several organizations support creative engagement with well and frail older adults, and several well-known programs target this population. The University of Wisconsin Center on Age & Community Web site has an extensive list of products and resources, including free, downloadable white papers on this issue (www.aging.uwm.eduwww.aging.uwm.eduwww.creativeaging.org

Also, she said, the Society for the Arts in Healthcare is in the process of putting together a primer aimed at helping artists learn how to work with frail older adults; the Museum of Modern Art, New York, has an elegant book called “Meet Me: Making Art Accessible to People with Dementia” that seeks to help museums begin education programs for people with dementia; and a book by John Zeisel, Ph.D., addresses the arts as part of a full treatment plan that also includes assessment of the environment (“I'm Still Here” [New York: Avery, 2009]).

In her book, “Forget Memory: Creating Better Lives for People With Dementia” (Baltimore: Johns Hopkins University Press, 2009), Dr. Basting highlights a range of arts programs designed for the elderly.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Creative engagement is to the aging brain as physical activity is to the aging body. Just as studies have shown older adults who maintain higher levels of muscle strength, flexibility, and aerobic capacity are healthier and better able to preserve their independent function longer than their more sedentary peers, an emerging body of literature suggests that those who engage in creative activities exhibit increased psychological well-being.

For example, findings from the federally funded Creativity and Aging study spearheaded by the late Dr. Gene D. Cohen and colleagues in the Center on Aging, Health, and Humanities at George Washington University, Washington, showed that participation in community-based cultural programs improved both the general health and mental health of older adults.

Specifically, the study recruited 300 healthy, ambulatory, older adults between the ages of 65 and 103 in New York, Washington, and San Francisco. Half of the participants were assigned to participate in professionally conducted arts programs, such as singing, creative writing, poetry, painting, or jewelry making, while the other half maintained usual activity.

Results from the Washington group showed that, after 2 years, the arts group reported better overall physical health, fewer doctor visits, fewer falls, and better scores on depression and loneliness scales. Additionally, the authors noted that participation in the community-based arts activities had a positive impact on the individuals' ability to maintain their independence by reducing the risk factors “that drive the need for long-term care” (Gerontologist 2006;46:726-34).

Other studies have produced similar findings. In 1999, Frederick Tims, Ph.D., professor and area chair of music therapy at Michigan State University, East Lansing, reported the results of the Music Making and Wellness Project in which the investigators compared the well-being of 61 older adults who were assigned to participate in group keyboard lessons with that of a control group of similar aged adults who did not participate. After the music intervention, the keyboard group showed significant decreases in anxiety, depression, and loneliness, and increasing levels of human growth hormone–which has been implicated in a range of age-related health conditions.

In 2004, investigators in the psychology and theatre departments at Elmhurst (Ill.) College, evaluated the impact that a short-term theater arts intervention had on the cognitive and affective functioning of older adults living in the community. A total of 124 participants aged 60–86 years were assigned to one of three group: theater arts, non–content specific visual arts, and no treatment. After 4 weeks, the adults in the theater arts group improved significantly more than the no-treatment control group in each of the four measures: word recall, memory, problem solving, and psychological well-being.

Adults in the visual arts group showed smaller improvements relative to the control group, according to the authors. Four months after the study, the theater group had maintained their performance improvements across all measures, they wrote. The authors concluded that theater training, even over a short time period, can help prevent cognitive decline associated with aging (J. Aging Health 2004;16:562-85).

Creative engagement also can improve the quality of life for adults with Alzheimer's disease and other age-related dementias. In an observational study published in 2005 in the American Journal of Alzheimer's Disease and Other Dementias, the well-being of 12 older adults with dementia improved while participating in an art program called Memories in the Making than they did during more-traditional adult day care activities.

Specifically, participants in the program, which encourages self-expression through the visual arts for adults in the early and middle stages of dementia, exhibited significantly more interest, sustained attention, pleasure, self-esteem, and normalcy during the intervention period (Am. J. Alzheimers Dis. Other Demen. 2005;20:220-7).

More recently, researchers from the University of Wisconsin's Center on Age and Community in Milwaukee reported that participation in a group storytelling program called TimeSlips, developed by the center's executive director Anne Basting, Ph.D., improved the alertness and level of engagement among individuals with dementia living in long-term care settings, compared with a control group of peers from nonparticipating facilities. The researchers also observed improved staff-resident interactions, social interactions, and social engagement in the participating centers (Gerontologist 2009;49:117-27).

Using the arts and creative engagement “gives us a way to focus on remaining strengths and even growth during a time that is perceived as an inevitable and total decline, which in turn brings meaning and hope to families and care providers alike,” Dr. Basting said in an interview.

The link between creative engagement and positive psychosocial outcomes in older adults can likely be attributed to multiple mechanisms. It is possible, according to Roberto Cabeza, Ph.D., professor of psychology and neuroscience in the Center for Cognitive Neuroscience at Duke University, Durham, N.C., that participating in activities that challenge the mind, such as artistic expression “stimulates the growth of new brain cells in the cerebral cortex.” Even as we age, he said, “the creation of new neuron networks continues.”

Susan H. McFadden, Ph.D., professor of psychology at the University of Wisconsin, Oshkosh, and coauthor with Dr. Basting of a paper titled “Healthy Aging Persons and Their Brains: Promoting Resilience Through Creative Engagement” published in February (Clin. Geriatr. Med. 2010;26:149-61), believes that one of the most fundamental mechanisms is the “sense of social connectedness” that comes from working together on projects related to the arts.

Other possible contributors are “the physical activity in some of these programs, the sense of optimism people feel about working together on something they all think is important, the positive emotions they experience, and a sense of mastery and hopefulness that comes from investing yourself in something important,” she said in an interview. “All of these have positive effects on the immune system, the endocrine system, and the nervous system.”

She said several organizations support creative engagement with well and frail older adults, and several well-known programs target this population. The University of Wisconsin Center on Age & Community Web site has an extensive list of products and resources, including free, downloadable white papers on this issue (www.aging.uwm.eduwww.aging.uwm.eduwww.creativeaging.org

Also, she said, the Society for the Arts in Healthcare is in the process of putting together a primer aimed at helping artists learn how to work with frail older adults; the Museum of Modern Art, New York, has an elegant book called “Meet Me: Making Art Accessible to People with Dementia” that seeks to help museums begin education programs for people with dementia; and a book by John Zeisel, Ph.D., addresses the arts as part of a full treatment plan that also includes assessment of the environment (“I'm Still Here” [New York: Avery, 2009]).

In her book, “Forget Memory: Creating Better Lives for People With Dementia” (Baltimore: Johns Hopkins University Press, 2009), Dr. Basting highlights a range of arts programs designed for the elderly.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

The grim economic picture that has dominated the news over the last year–the stock market plunges, bank failures, mortgage foreclosures, and job losses–has had a dramatic impact on our nation's psyche.

Earlier this year, the results of a Gallup-Healthways poll assessing the nation's mood showed a significant drop in emotional well-being between February 2008 and February 2009, correlating with economic indicators. The ongoing daily survey of more than 355,000 people showed that the Emotional Health subindex–a measure that gauges individuals' emotional status by weighing negative factors such as depression, anxiety, stress, and worry, against self-reported positive feelings–plummeted on days when there was bad news from the financial sector.

The state of the economy and concern over personal finances were the top stressors named by U.S. residents responding to an online survey conducted by the American Psychological Association (APA). Specifically, about 80% of the nearly 2,000 people who responded to the 2008 Stress in America survey reported in September 2008 that the economy was a significant source of stress–up from 66% just 4 months earlier–and 81% reported money-related anxieties, up from 75% in April.

“When asked about the recent financial crisis, almost half (46%) of Americans say that they are increasingly stressed about their ability to provide for their family's basic needs,” an executive summary of the survey results said.

The prominence of financial woes on the stress spectrum is notable, according to Katherine Nordal, Ph.D., the APA's executive director for professional practice. Although money worries often emerge as a source of stress, historically, they have not been the top stressors, she said. “Most people are driven to counseling because of relationship problems with marriage and children, depression, and anxiety. But what we're seeing today is that the economy and finances are viewed as significantly more stressful, by more than 8 out of 10 Americans.”

The increased stress associated with financial concerns is exacting an emotional and physical toll, Dr. Nordal said. Irritability, anxiety, anger, fatigue, depression, muscle tension, sadness, and lack of motivation were among the stress-related consequences most commonly reported in the APA survey, Dr. Nordal noted. Many of the respondents reported a greater reliance on unhealthy behaviors for dealing with stress, including smoking, and drinking alcohol, she said.

For more and more people, the addition or exacerbation of finance-related stress might prove life threatening, said Richard McKeon, Ph.D., suicide prevention public health adviser with the Substance Abuse Mental Health Services Association (SAMHSA). Between January 2008 and January 2009, the number of calls to SAMHSA's National Suicide Prevention Lifeline increased 36%, from 402,167 to 545,851, with “a significant increase in the number of people who are giving economic reasons for calling,” he said.

Also, the Suicide Prevention Resource Center (SPRC), a health and human development project of the Massachusetts-based Education Development Center, recently conducted a literature review of the relevant research from the past 20 years, and identified a strong relationship between unemployment, the economy, and suicide. A common chain of adversity emerged, with job loss frequently serving as the catalyst for subsequent anxiety and depression and, with the associated financial strain, a loss of personal control–all factors that could lead to suicide attempts in vulnerable people, the SPRC report showed.

In fact, the emotions that many people are experiencing tied to their economic struggles “parallel the loss and grief felt as a result of more 'typical' disasters,” according to A. Kathryn Power, M.Ed., director of SAMHSA's Center for Mental Health Services. Both types of situations can result in high levels of stress, depression, feelings of helplessness, and suicidal ideation, she said in a keynote address at the U.S. Department of Health and Human Services All-Hazards Disaster Behavioral Health: Optimizing Psychological Health and Resiliency in Difficult Economic Times conference held in April of this year.

Job loss, in particular, triggers a “cascade of stressors,” said Richard H. Price, Ph.D., in which the associated financial strain and loss of personal control lead to anxiety, depression, impaired functioning, poor health, and relationship conflicts across all demographic and socioeconomic buffers. In a 2002 paper published in the Journal of Occupational Health Psychology, Dr. Price and his colleagues in the Department of Psychology and Institute for Social Research at the University of Michigan, Ann Arbor, reported the results of a 2-year longitudinal study of 756 people who experienced involuntary job loss and had been unemployed for at least 3 months with no chance of being recalled to their former position.

The chain of negative life events stemming from the financial strain of lost income was associated with increased rates of depression, impaired emotional functioning, and self-reports of poor health, which in turn affected job search efforts and chance of reemployment, according to the investigators. The adverse effects were mediated by individuals' perception of reduced personal control, they wrote, noting that certain protective factors, including a second impact or strong social support, had a buffering effect.

The investigators also determined that the psychological effects of job loss were not short-lived. At 6-month and 2-year follow-up, when 60% and 71% of the study participants, respectively, had been re-employed, the depression and perceived loss of personal control remained evident, they wrote (J. Occup. Health Psychol. 2002;7:302-12).

Many of these negative effects are preventable through interventions that empower people in the face of adversity, according to Dr. Price, who, along with his colleagues, developed such an intervention in the early 1980s that is still being used. Called the JOBS program, the intervention teaches trainers–often teachers, social workers, or others who themselves have been unemployed–to help participants develop the necessary practical skills and self-confidence they will need in order to get new jobs. In 5-day workshops, participants learn job-search strategies, practice interviewing skills, and engage in role-play and problem-solving activities aimed at helping them cope.

Randomized trials conducted in the United States and Finland have shown that people who complete the program find new jobs faster than those who do not, are reemployed in higher paying positions; and experience fewer job-loss related negative mental health consequences (J. Health Soc. Behav. 1992;33:158-67; Am. J. Community Psychol. 1995;23:39-74; J. Occup. Health Psychol. 2002;7:5-19).

The positive impact of the intervention remained evident 2 years after participation, an analysis of the long-term effects of the program show. By using data from the initial randomized field experiment conducted in 1995, the Michigan investigators determined that, 2 years post intervention, program participants had “significantly higher levels of reemployment and monthly income, lower levels of depressive symptoms, lower likelihood of experiencing a major depressive episode in the last year, and better role and emotional functioning compared with the control group.”

Job-search motivation and sense of mastery at baseline “had both direct and interactive effects on reemployment and mental health outcomes, respectively,” they wrote, noting that participants who initially had lower levels of job-search motivation and mastery benefited the most (J. Occup. Health Psychol. 2000;5:32-47).

Empowering those struggling emotionally during the economic crisis is also the goal of a new Web-based guide developed by SAMHSA called “Getting Through Tough Economic Times” (www.samhsa.gov/economy).

By Diana Mahoney, Share your thoughts and suggestions at cpnews@elsevier.com 

The grim economic picture that has dominated the news over the last year–the stock market plunges, bank failures, mortgage foreclosures, and job losses–has had a dramatic impact on our nation's psyche.

Earlier this year, the results of a Gallup-Healthways poll assessing the nation's mood showed a significant drop in emotional well-being between February 2008 and February 2009, correlating with economic indicators. The ongoing daily survey of more than 355,000 people showed that the Emotional Health subindex–a measure that gauges individuals' emotional status by weighing negative factors such as depression, anxiety, stress, and worry, against self-reported positive feelings–plummeted on days when there was bad news from the financial sector.

The state of the economy and concern over personal finances were the top stressors named by U.S. residents responding to an online survey conducted by the American Psychological Association (APA). Specifically, about 80% of the nearly 2,000 people who responded to the 2008 Stress in America survey reported in September 2008 that the economy was a significant source of stress–up from 66% just 4 months earlier–and 81% reported money-related anxieties, up from 75% in April.

“When asked about the recent financial crisis, almost half (46%) of Americans say that they are increasingly stressed about their ability to provide for their family's basic needs,” an executive summary of the survey results said.

The prominence of financial woes on the stress spectrum is notable, according to Katherine Nordal, Ph.D., the APA's executive director for professional practice. Although money worries often emerge as a source of stress, historically, they have not been the top stressors, she said. “Most people are driven to counseling because of relationship problems with marriage and children, depression, and anxiety. But what we're seeing today is that the economy and finances are viewed as significantly more stressful, by more than 8 out of 10 Americans.”

The increased stress associated with financial concerns is exacting an emotional and physical toll, Dr. Nordal said. Irritability, anxiety, anger, fatigue, depression, muscle tension, sadness, and lack of motivation were among the stress-related consequences most commonly reported in the APA survey, Dr. Nordal noted. Many of the respondents reported a greater reliance on unhealthy behaviors for dealing with stress, including smoking, and drinking alcohol, she said.

For more and more people, the addition or exacerbation of finance-related stress might prove life threatening, said Richard McKeon, Ph.D., suicide prevention public health adviser with the Substance Abuse Mental Health Services Association (SAMHSA). Between January 2008 and January 2009, the number of calls to SAMHSA's National Suicide Prevention Lifeline increased 36%, from 402,167 to 545,851, with “a significant increase in the number of people who are giving economic reasons for calling,” he said.

Also, the Suicide Prevention Resource Center (SPRC), a health and human development project of the Massachusetts-based Education Development Center, recently conducted a literature review of the relevant research from the past 20 years, and identified a strong relationship between unemployment, the economy, and suicide. A common chain of adversity emerged, with job loss frequently serving as the catalyst for subsequent anxiety and depression and, with the associated financial strain, a loss of personal control–all factors that could lead to suicide attempts in vulnerable people, the SPRC report showed.

In fact, the emotions that many people are experiencing tied to their economic struggles “parallel the loss and grief felt as a result of more 'typical' disasters,” according to A. Kathryn Power, M.Ed., director of SAMHSA's Center for Mental Health Services. Both types of situations can result in high levels of stress, depression, feelings of helplessness, and suicidal ideation, she said in a keynote address at the U.S. Department of Health and Human Services All-Hazards Disaster Behavioral Health: Optimizing Psychological Health and Resiliency in Difficult Economic Times conference held in April of this year.

Job loss, in particular, triggers a “cascade of stressors,” said Richard H. Price, Ph.D., in which the associated financial strain and loss of personal control lead to anxiety, depression, impaired functioning, poor health, and relationship conflicts across all demographic and socioeconomic buffers. In a 2002 paper published in the Journal of Occupational Health Psychology, Dr. Price and his colleagues in the Department of Psychology and Institute for Social Research at the University of Michigan, Ann Arbor, reported the results of a 2-year longitudinal study of 756 people who experienced involuntary job loss and had been unemployed for at least 3 months with no chance of being recalled to their former position.

The chain of negative life events stemming from the financial strain of lost income was associated with increased rates of depression, impaired emotional functioning, and self-reports of poor health, which in turn affected job search efforts and chance of reemployment, according to the investigators. The adverse effects were mediated by individuals' perception of reduced personal control, they wrote, noting that certain protective factors, including a second impact or strong social support, had a buffering effect.

The investigators also determined that the psychological effects of job loss were not short-lived. At 6-month and 2-year follow-up, when 60% and 71% of the study participants, respectively, had been re-employed, the depression and perceived loss of personal control remained evident, they wrote (J. Occup. Health Psychol. 2002;7:302-12).

Many of these negative effects are preventable through interventions that empower people in the face of adversity, according to Dr. Price, who, along with his colleagues, developed such an intervention in the early 1980s that is still being used. Called the JOBS program, the intervention teaches trainers–often teachers, social workers, or others who themselves have been unemployed–to help participants develop the necessary practical skills and self-confidence they will need in order to get new jobs. In 5-day workshops, participants learn job-search strategies, practice interviewing skills, and engage in role-play and problem-solving activities aimed at helping them cope.

Randomized trials conducted in the United States and Finland have shown that people who complete the program find new jobs faster than those who do not, are reemployed in higher paying positions; and experience fewer job-loss related negative mental health consequences (J. Health Soc. Behav. 1992;33:158-67; Am. J. Community Psychol. 1995;23:39-74; J. Occup. Health Psychol. 2002;7:5-19).

The positive impact of the intervention remained evident 2 years after participation, an analysis of the long-term effects of the program show. By using data from the initial randomized field experiment conducted in 1995, the Michigan investigators determined that, 2 years post intervention, program participants had “significantly higher levels of reemployment and monthly income, lower levels of depressive symptoms, lower likelihood of experiencing a major depressive episode in the last year, and better role and emotional functioning compared with the control group.”

Job-search motivation and sense of mastery at baseline “had both direct and interactive effects on reemployment and mental health outcomes, respectively,” they wrote, noting that participants who initially had lower levels of job-search motivation and mastery benefited the most (J. Occup. Health Psychol. 2000;5:32-47).

Empowering those struggling emotionally during the economic crisis is also the goal of a new Web-based guide developed by SAMHSA called “Getting Through Tough Economic Times” (www.samhsa.gov/economy).

By Diana Mahoney, Share your thoughts and suggestions at cpnews@elsevier.com 

The grim economic picture that has dominated the news over the last year–the stock market plunges, bank failures, mortgage foreclosures, and job losses–has had a dramatic impact on our nation's psyche.

Earlier this year, the results of a Gallup-Healthways poll assessing the nation's mood showed a significant drop in emotional well-being between February 2008 and February 2009, correlating with economic indicators. The ongoing daily survey of more than 355,000 people showed that the Emotional Health subindex–a measure that gauges individuals' emotional status by weighing negative factors such as depression, anxiety, stress, and worry, against self-reported positive feelings–plummeted on days when there was bad news from the financial sector.

The state of the economy and concern over personal finances were the top stressors named by U.S. residents responding to an online survey conducted by the American Psychological Association (APA). Specifically, about 80% of the nearly 2,000 people who responded to the 2008 Stress in America survey reported in September 2008 that the economy was a significant source of stress–up from 66% just 4 months earlier–and 81% reported money-related anxieties, up from 75% in April.

“When asked about the recent financial crisis, almost half (46%) of Americans say that they are increasingly stressed about their ability to provide for their family's basic needs,” an executive summary of the survey results said.

The prominence of financial woes on the stress spectrum is notable, according to Katherine Nordal, Ph.D., the APA's executive director for professional practice. Although money worries often emerge as a source of stress, historically, they have not been the top stressors, she said. “Most people are driven to counseling because of relationship problems with marriage and children, depression, and anxiety. But what we're seeing today is that the economy and finances are viewed as significantly more stressful, by more than 8 out of 10 Americans.”

The increased stress associated with financial concerns is exacting an emotional and physical toll, Dr. Nordal said. Irritability, anxiety, anger, fatigue, depression, muscle tension, sadness, and lack of motivation were among the stress-related consequences most commonly reported in the APA survey, Dr. Nordal noted. Many of the respondents reported a greater reliance on unhealthy behaviors for dealing with stress, including smoking, and drinking alcohol, she said.

For more and more people, the addition or exacerbation of finance-related stress might prove life threatening, said Richard McKeon, Ph.D., suicide prevention public health adviser with the Substance Abuse Mental Health Services Association (SAMHSA). Between January 2008 and January 2009, the number of calls to SAMHSA's National Suicide Prevention Lifeline increased 36%, from 402,167 to 545,851, with “a significant increase in the number of people who are giving economic reasons for calling,” he said.

Also, the Suicide Prevention Resource Center (SPRC), a health and human development project of the Massachusetts-based Education Development Center, recently conducted a literature review of the relevant research from the past 20 years, and identified a strong relationship between unemployment, the economy, and suicide. A common chain of adversity emerged, with job loss frequently serving as the catalyst for subsequent anxiety and depression and, with the associated financial strain, a loss of personal control–all factors that could lead to suicide attempts in vulnerable people, the SPRC report showed.

In fact, the emotions that many people are experiencing tied to their economic struggles “parallel the loss and grief felt as a result of more 'typical' disasters,” according to A. Kathryn Power, M.Ed., director of SAMHSA's Center for Mental Health Services. Both types of situations can result in high levels of stress, depression, feelings of helplessness, and suicidal ideation, she said in a keynote address at the U.S. Department of Health and Human Services All-Hazards Disaster Behavioral Health: Optimizing Psychological Health and Resiliency in Difficult Economic Times conference held in April of this year.

Job loss, in particular, triggers a “cascade of stressors,” said Richard H. Price, Ph.D., in which the associated financial strain and loss of personal control lead to anxiety, depression, impaired functioning, poor health, and relationship conflicts across all demographic and socioeconomic buffers. In a 2002 paper published in the Journal of Occupational Health Psychology, Dr. Price and his colleagues in the Department of Psychology and Institute for Social Research at the University of Michigan, Ann Arbor, reported the results of a 2-year longitudinal study of 756 people who experienced involuntary job loss and had been unemployed for at least 3 months with no chance of being recalled to their former position.

The chain of negative life events stemming from the financial strain of lost income was associated with increased rates of depression, impaired emotional functioning, and self-reports of poor health, which in turn affected job search efforts and chance of reemployment, according to the investigators. The adverse effects were mediated by individuals' perception of reduced personal control, they wrote, noting that certain protective factors, including a second impact or strong social support, had a buffering effect.

The investigators also determined that the psychological effects of job loss were not short-lived. At 6-month and 2-year follow-up, when 60% and 71% of the study participants, respectively, had been re-employed, the depression and perceived loss of personal control remained evident, they wrote (J. Occup. Health Psychol. 2002;7:302-12).

Many of these negative effects are preventable through interventions that empower people in the face of adversity, according to Dr. Price, who, along with his colleagues, developed such an intervention in the early 1980s that is still being used. Called the JOBS program, the intervention teaches trainers–often teachers, social workers, or others who themselves have been unemployed–to help participants develop the necessary practical skills and self-confidence they will need in order to get new jobs. In 5-day workshops, participants learn job-search strategies, practice interviewing skills, and engage in role-play and problem-solving activities aimed at helping them cope.

Randomized trials conducted in the United States and Finland have shown that people who complete the program find new jobs faster than those who do not, are reemployed in higher paying positions; and experience fewer job-loss related negative mental health consequences (J. Health Soc. Behav. 1992;33:158-67; Am. J. Community Psychol. 1995;23:39-74; J. Occup. Health Psychol. 2002;7:5-19).

The positive impact of the intervention remained evident 2 years after participation, an analysis of the long-term effects of the program show. By using data from the initial randomized field experiment conducted in 1995, the Michigan investigators determined that, 2 years post intervention, program participants had “significantly higher levels of reemployment and monthly income, lower levels of depressive symptoms, lower likelihood of experiencing a major depressive episode in the last year, and better role and emotional functioning compared with the control group.”

Job-search motivation and sense of mastery at baseline “had both direct and interactive effects on reemployment and mental health outcomes, respectively,” they wrote, noting that participants who initially had lower levels of job-search motivation and mastery benefited the most (J. Occup. Health Psychol. 2000;5:32-47).

Empowering those struggling emotionally during the economic crisis is also the goal of a new Web-based guide developed by SAMHSA called “Getting Through Tough Economic Times” (www.samhsa.gov/economy).

By Diana Mahoney, Share your thoughts and suggestions at cpnews@elsevier.com 

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Mild traumatic brain injury is a “silent epidemic,” according to the Centers for Disease Control and Prevention. But the condition has been generating a lot of noise recently.

Reports of studies showing a link between mild traumatic brain injury, or concussion, and lingering alterations in cognitive and motor function in high-profile populations, such as U.S. soldiers returning from Iraq and Afghanistan, college athletes, and professional football players, have begun to give voice to the potential public health burden imposed by such injuries.

Generally defined as a head injury resulting from contact or acceleration or deceleration forces that induce an alteration in mental status (with or without a loss of consciousness) and a Glasgow Coma Scale score of 13–15, mild traumatic brain injury (mTBI) accounts for as many as 90% of all cases of head injury, World Health Organization estimates show.

The acute, outward signs and symptoms of this type of injury appear to be short lived, and patients, families, and even clinicians historically have minimized the potential relationship between the injury and subsequent symptoms of cognitive or other impairment. There is considerable literature reporting the strong association between TBI and psychiatric disorders. Major depression is the most prevalent psychiatric disorder after TBI, with estimated rates ranging from 14% to 77%, according to Theresa A. Ashman, Ph.D., of the Mount Sinai School of Medicine, New York.

In one often-cited study, Dr. Jesse R. Fann of the University of Washington, Seattle, and colleagues investigated the risk of psychiatric illness after TBI among patients in an adult health maintenance organization. Of 939 patients diagnosed with TBI in 1993, the prevalence of any psychiatric illness in the first year after mild TBI was 34%, compared with 18% in the non-TBI control group (Arch. Gen. Psychiatry 2004;61:53–61).

More recently, a study of 2,552 retired professional football players showed a significant association between recurrent concussion and a diagnosis of clinical depression. Compared with retired players without a history of concussion, those who experienced three or more previous concussions were three times more likely to be diagnosed with depression, and those with a history of one or two previous concussions were 1.5 more likely to be diagnosed with depression, reported lead investigator Kevin M. Guskiewicz, Ph.D. (Med. Sci. Sports Exerc. 2007;39:903–9).

“Traditionally, it was thought that depression following a mild head injury was a reaction to the fact that the person had an accident or, for an athlete, he or she could not return to play,” said neuropsychologist Alain Ptito, Ph.D., of the Montreal Neurological Institute and Hospital. Dr. Ptito and his colleagues recently used magnetic resonance imaging to identify neural substrates of depression symptoms related to mTBI in 56 male athletes. “Our study clearly demonstrates that the story is not that simple–that depression [in this population] seems to originate from a cerebral dysfunction.

“The athletes with concussion and depression symptoms showed reduced activation in the dorsolateral prefrontal cortex and striatum and attenuated deactivation in medial frontal and temporal regions,” the authors wrote. “The severity of symptoms of depression correlated with neural responses in brain areas that are implicated in major depression” (Arch. Gen. Psychiatry 2008;65:81–9).

Screening for depression in post-mTBI patients can take as little as 5 minutes and can be achieved by telephone, according to Harvey S. Levin, Ph.D., of Baylor College of Medicine in Houston. Dr. Levin and his colleagues developed a prediction model using a brief screening measure for depression to identify patients with mTBI at high risk for a major depressive episode by 3 months post injury.

The investigators recruited a prospective cohort of 129 consecutive adults with mTBI who were evaluated at a large, metropolitan Level I trauma center. All of the patients underwent CT scans within 24 hours of their injury. They also completed the self-report Center for Epidemiologic Studies Depression scale (CES-D) at 1 week post injury and the current major depressive episode module of the Structured Clinical Interview for the DSM-IV at 3 months post injury.

Logistic regression was used to generate a prediction model of a major depressive episode at 3 months post injury using the CES-D score as an independent variable. Major depressive episode was present in 15 subjects at 3 months post injury (Arch. Gen. Psychiatry 2005;62:523–8).

The findings support the feasibility of the early detection of patients with mTBI who are at high risk for developing major depression, the authors wrote.

The findings also raise the possibility that coordinating outpatient psychiatric services with trauma centers could improve outcomes associated with mTBI by mitigating secondary conditions, they said.

In addition to screening for depression among mTBI patients, consistent screening for mTBI among patients with psychiatric symptoms should be mandated, Dr. Ashman said. Such screening is especially important in practices involving populations where “hidden TBI” is known or suspected to be common such as athletes and the elderly.

The treatment of depression secondary to mTBI should be approached from a multidisciplinary perspective. “When possible, individuals with TBI should have a neuropsychological evaluation to determine the nature and extent of the cognitive impairments and plan treatment,” Dr. Ashman and colleagues wrote in a review article of the neurobehavioral consequences of traumatic brain injury.

“Remediation, which may be coupled with psychotherapy, can then be provided by rehabilitation psychologists or neuropsychologists, in conjunction with speech therapists, occupational therapists and other rehabilitation professionals” (Mt. Sinai J. Med. 2006;73:999–1005).

No medication has received approval from the Food and Drug Administration for the treatment of any neuropsychiatric consequence of mTBI, but antidepressant therapy has been shown to improve mood and, potentially, cognitive performance in these patients.

In a 2001 study, for example, Dr. Fann and colleagues conducted an 8-week, nonrandomized, single-blind, placebo run-in trial of sertraline in a group of 15 patients with mTBI and depression.

The investigators conducted neuropsychological testing before and after the treatment trial. Compared with baseline, depression scores improved significantly, as did measures of psychomotor speed, recent verbal memory, recent visual memory, and general cognitive efficacy improved with treatment, the authors wrote.

When pharmacotherapy is considered in this population, it is essential to start medications at low doses and to titrate slowly because of the potential susceptibility to adverse cognitive effects, Dr. Ashman said.

It is best to avoid medications that are highly sedative and those that have deleterious effects on the central nervous system, she noted.

Finally, education is a key component of depression management in mTBI. Education after mTBI for the patient as well as family, friends, employers, and others, should begin early and include an explanation of the range of possible symptoms, the usual time course for resolution, and the potential for long-term problems, according Dr. David B. Arciniegas of the University of Colorado, Denver.

Also, “the clinician should offer validation of the person's experience of symptoms,” and couple the validation with the development of realistic goals aimed at returning to normal activities, he said.

PERSPECTIVE

Until recently, mild traumatic brain injury was presumed to be not very important for generating long-term symptoms or problems. In fact, this consideration was a huge source of contention among those who granted disability status of patients with mild TBI.

Also, disagreement prevailed within legal circles about various injury-related lawsuits, as most companies did not want to pay for the post-mTBI headaches, symptoms of depression, insomnia, and so forth.

Similarly, mTBI has been underconsidered as a source of psychiatric symptoms among mental health clinicians. Few psychiatrists routinely ask patients about mTBI.

This mind-set might be exacerbated by the fact that when there is no loss of consciousness associated with a head injury, individuals often don't seek medical care, and by the measures used to gauge the severity of head trauma and the nomenclature used to describe it.

The term “mild” with respect to traumatic brain injury does not reflect the severity of the injury, but rather the length of time the individual experiences postinjury confusion or disorientation.

On the Glasgow Coma Scale, an injury causing less than 30 minutes of altered consciousness is deemed mild. To patients, families, and even clinicians, that connotation might minimize the awareness of the potential for long-term symptoms.

Since neuroimaging has become more readily available and the science has become more specific, mTBI and the possibility of postinjury symptoms have recently gained more traction. But there is still no way to show cause and effect between mTBI and the broad range of neuropsychiatric symptoms that have been attributed to it.

Until research catches up with reality, the best way to manage psychiatric symptoms in mTBI patients is to first identify such patients through routine history and, educate the patient and family, validate the patient's symptoms, and treat with therapy and medication.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Mild traumatic brain injury is a “silent epidemic,” according to the Centers for Disease Control and Prevention. But the condition has been generating a lot of noise recently.

Reports of studies showing a link between mild traumatic brain injury, or concussion, and lingering alterations in cognitive and motor function in high-profile populations, such as U.S. soldiers returning from Iraq and Afghanistan, college athletes, and professional football players, have begun to give voice to the potential public health burden imposed by such injuries.

Generally defined as a head injury resulting from contact or acceleration or deceleration forces that induce an alteration in mental status (with or without a loss of consciousness) and a Glasgow Coma Scale score of 13–15, mild traumatic brain injury (mTBI) accounts for as many as 90% of all cases of head injury, World Health Organization estimates show.

The acute, outward signs and symptoms of this type of injury appear to be short lived, and patients, families, and even clinicians historically have minimized the potential relationship between the injury and subsequent symptoms of cognitive or other impairment. There is considerable literature reporting the strong association between TBI and psychiatric disorders. Major depression is the most prevalent psychiatric disorder after TBI, with estimated rates ranging from 14% to 77%, according to Theresa A. Ashman, Ph.D., of the Mount Sinai School of Medicine, New York.

In one often-cited study, Dr. Jesse R. Fann of the University of Washington, Seattle, and colleagues investigated the risk of psychiatric illness after TBI among patients in an adult health maintenance organization. Of 939 patients diagnosed with TBI in 1993, the prevalence of any psychiatric illness in the first year after mild TBI was 34%, compared with 18% in the non-TBI control group (Arch. Gen. Psychiatry 2004;61:53–61).

More recently, a study of 2,552 retired professional football players showed a significant association between recurrent concussion and a diagnosis of clinical depression. Compared with retired players without a history of concussion, those who experienced three or more previous concussions were three times more likely to be diagnosed with depression, and those with a history of one or two previous concussions were 1.5 more likely to be diagnosed with depression, reported lead investigator Kevin M. Guskiewicz, Ph.D. (Med. Sci. Sports Exerc. 2007;39:903–9).

“Traditionally, it was thought that depression following a mild head injury was a reaction to the fact that the person had an accident or, for an athlete, he or she could not return to play,” said neuropsychologist Alain Ptito, Ph.D., of the Montreal Neurological Institute and Hospital. Dr. Ptito and his colleagues recently used magnetic resonance imaging to identify neural substrates of depression symptoms related to mTBI in 56 male athletes. “Our study clearly demonstrates that the story is not that simple–that depression [in this population] seems to originate from a cerebral dysfunction.

“The athletes with concussion and depression symptoms showed reduced activation in the dorsolateral prefrontal cortex and striatum and attenuated deactivation in medial frontal and temporal regions,” the authors wrote. “The severity of symptoms of depression correlated with neural responses in brain areas that are implicated in major depression” (Arch. Gen. Psychiatry 2008;65:81–9).

Screening for depression in post-mTBI patients can take as little as 5 minutes and can be achieved by telephone, according to Harvey S. Levin, Ph.D., of Baylor College of Medicine in Houston. Dr. Levin and his colleagues developed a prediction model using a brief screening measure for depression to identify patients with mTBI at high risk for a major depressive episode by 3 months post injury.

The investigators recruited a prospective cohort of 129 consecutive adults with mTBI who were evaluated at a large, metropolitan Level I trauma center. All of the patients underwent CT scans within 24 hours of their injury. They also completed the self-report Center for Epidemiologic Studies Depression scale (CES-D) at 1 week post injury and the current major depressive episode module of the Structured Clinical Interview for the DSM-IV at 3 months post injury.

Logistic regression was used to generate a prediction model of a major depressive episode at 3 months post injury using the CES-D score as an independent variable. Major depressive episode was present in 15 subjects at 3 months post injury (Arch. Gen. Psychiatry 2005;62:523–8).

The findings support the feasibility of the early detection of patients with mTBI who are at high risk for developing major depression, the authors wrote.

The findings also raise the possibility that coordinating outpatient psychiatric services with trauma centers could improve outcomes associated with mTBI by mitigating secondary conditions, they said.

In addition to screening for depression among mTBI patients, consistent screening for mTBI among patients with psychiatric symptoms should be mandated, Dr. Ashman said. Such screening is especially important in practices involving populations where “hidden TBI” is known or suspected to be common such as athletes and the elderly.

The treatment of depression secondary to mTBI should be approached from a multidisciplinary perspective. “When possible, individuals with TBI should have a neuropsychological evaluation to determine the nature and extent of the cognitive impairments and plan treatment,” Dr. Ashman and colleagues wrote in a review article of the neurobehavioral consequences of traumatic brain injury.

“Remediation, which may be coupled with psychotherapy, can then be provided by rehabilitation psychologists or neuropsychologists, in conjunction with speech therapists, occupational therapists and other rehabilitation professionals” (Mt. Sinai J. Med. 2006;73:999–1005).

No medication has received approval from the Food and Drug Administration for the treatment of any neuropsychiatric consequence of mTBI, but antidepressant therapy has been shown to improve mood and, potentially, cognitive performance in these patients.

In a 2001 study, for example, Dr. Fann and colleagues conducted an 8-week, nonrandomized, single-blind, placebo run-in trial of sertraline in a group of 15 patients with mTBI and depression.

The investigators conducted neuropsychological testing before and after the treatment trial. Compared with baseline, depression scores improved significantly, as did measures of psychomotor speed, recent verbal memory, recent visual memory, and general cognitive efficacy improved with treatment, the authors wrote.

When pharmacotherapy is considered in this population, it is essential to start medications at low doses and to titrate slowly because of the potential susceptibility to adverse cognitive effects, Dr. Ashman said.

It is best to avoid medications that are highly sedative and those that have deleterious effects on the central nervous system, she noted.

Finally, education is a key component of depression management in mTBI. Education after mTBI for the patient as well as family, friends, employers, and others, should begin early and include an explanation of the range of possible symptoms, the usual time course for resolution, and the potential for long-term problems, according Dr. David B. Arciniegas of the University of Colorado, Denver.

Also, “the clinician should offer validation of the person's experience of symptoms,” and couple the validation with the development of realistic goals aimed at returning to normal activities, he said.

PERSPECTIVE

Until recently, mild traumatic brain injury was presumed to be not very important for generating long-term symptoms or problems. In fact, this consideration was a huge source of contention among those who granted disability status of patients with mild TBI.

Also, disagreement prevailed within legal circles about various injury-related lawsuits, as most companies did not want to pay for the post-mTBI headaches, symptoms of depression, insomnia, and so forth.

Similarly, mTBI has been underconsidered as a source of psychiatric symptoms among mental health clinicians. Few psychiatrists routinely ask patients about mTBI.

This mind-set might be exacerbated by the fact that when there is no loss of consciousness associated with a head injury, individuals often don't seek medical care, and by the measures used to gauge the severity of head trauma and the nomenclature used to describe it.

The term “mild” with respect to traumatic brain injury does not reflect the severity of the injury, but rather the length of time the individual experiences postinjury confusion or disorientation.

On the Glasgow Coma Scale, an injury causing less than 30 minutes of altered consciousness is deemed mild. To patients, families, and even clinicians, that connotation might minimize the awareness of the potential for long-term symptoms.

Since neuroimaging has become more readily available and the science has become more specific, mTBI and the possibility of postinjury symptoms have recently gained more traction. But there is still no way to show cause and effect between mTBI and the broad range of neuropsychiatric symptoms that have been attributed to it.

Until research catches up with reality, the best way to manage psychiatric symptoms in mTBI patients is to first identify such patients through routine history and, educate the patient and family, validate the patient's symptoms, and treat with therapy and medication.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Mild traumatic brain injury is a “silent epidemic,” according to the Centers for Disease Control and Prevention. But the condition has been generating a lot of noise recently.

Reports of studies showing a link between mild traumatic brain injury, or concussion, and lingering alterations in cognitive and motor function in high-profile populations, such as U.S. soldiers returning from Iraq and Afghanistan, college athletes, and professional football players, have begun to give voice to the potential public health burden imposed by such injuries.

Generally defined as a head injury resulting from contact or acceleration or deceleration forces that induce an alteration in mental status (with or without a loss of consciousness) and a Glasgow Coma Scale score of 13–15, mild traumatic brain injury (mTBI) accounts for as many as 90% of all cases of head injury, World Health Organization estimates show.

The acute, outward signs and symptoms of this type of injury appear to be short lived, and patients, families, and even clinicians historically have minimized the potential relationship between the injury and subsequent symptoms of cognitive or other impairment. There is considerable literature reporting the strong association between TBI and psychiatric disorders. Major depression is the most prevalent psychiatric disorder after TBI, with estimated rates ranging from 14% to 77%, according to Theresa A. Ashman, Ph.D., of the Mount Sinai School of Medicine, New York.

In one often-cited study, Dr. Jesse R. Fann of the University of Washington, Seattle, and colleagues investigated the risk of psychiatric illness after TBI among patients in an adult health maintenance organization. Of 939 patients diagnosed with TBI in 1993, the prevalence of any psychiatric illness in the first year after mild TBI was 34%, compared with 18% in the non-TBI control group (Arch. Gen. Psychiatry 2004;61:53–61).

More recently, a study of 2,552 retired professional football players showed a significant association between recurrent concussion and a diagnosis of clinical depression. Compared with retired players without a history of concussion, those who experienced three or more previous concussions were three times more likely to be diagnosed with depression, and those with a history of one or two previous concussions were 1.5 more likely to be diagnosed with depression, reported lead investigator Kevin M. Guskiewicz, Ph.D. (Med. Sci. Sports Exerc. 2007;39:903–9).

“Traditionally, it was thought that depression following a mild head injury was a reaction to the fact that the person had an accident or, for an athlete, he or she could not return to play,” said neuropsychologist Alain Ptito, Ph.D., of the Montreal Neurological Institute and Hospital. Dr. Ptito and his colleagues recently used magnetic resonance imaging to identify neural substrates of depression symptoms related to mTBI in 56 male athletes. “Our study clearly demonstrates that the story is not that simple–that depression [in this population] seems to originate from a cerebral dysfunction.

“The athletes with concussion and depression symptoms showed reduced activation in the dorsolateral prefrontal cortex and striatum and attenuated deactivation in medial frontal and temporal regions,” the authors wrote. “The severity of symptoms of depression correlated with neural responses in brain areas that are implicated in major depression” (Arch. Gen. Psychiatry 2008;65:81–9).

Screening for depression in post-mTBI patients can take as little as 5 minutes and can be achieved by telephone, according to Harvey S. Levin, Ph.D., of Baylor College of Medicine in Houston. Dr. Levin and his colleagues developed a prediction model using a brief screening measure for depression to identify patients with mTBI at high risk for a major depressive episode by 3 months post injury.

The investigators recruited a prospective cohort of 129 consecutive adults with mTBI who were evaluated at a large, metropolitan Level I trauma center. All of the patients underwent CT scans within 24 hours of their injury. They also completed the self-report Center for Epidemiologic Studies Depression scale (CES-D) at 1 week post injury and the current major depressive episode module of the Structured Clinical Interview for the DSM-IV at 3 months post injury.

Logistic regression was used to generate a prediction model of a major depressive episode at 3 months post injury using the CES-D score as an independent variable. Major depressive episode was present in 15 subjects at 3 months post injury (Arch. Gen. Psychiatry 2005;62:523–8).

The findings support the feasibility of the early detection of patients with mTBI who are at high risk for developing major depression, the authors wrote.

The findings also raise the possibility that coordinating outpatient psychiatric services with trauma centers could improve outcomes associated with mTBI by mitigating secondary conditions, they said.

In addition to screening for depression among mTBI patients, consistent screening for mTBI among patients with psychiatric symptoms should be mandated, Dr. Ashman said. Such screening is especially important in practices involving populations where “hidden TBI” is known or suspected to be common such as athletes and the elderly.

The treatment of depression secondary to mTBI should be approached from a multidisciplinary perspective. “When possible, individuals with TBI should have a neuropsychological evaluation to determine the nature and extent of the cognitive impairments and plan treatment,” Dr. Ashman and colleagues wrote in a review article of the neurobehavioral consequences of traumatic brain injury.

“Remediation, which may be coupled with psychotherapy, can then be provided by rehabilitation psychologists or neuropsychologists, in conjunction with speech therapists, occupational therapists and other rehabilitation professionals” (Mt. Sinai J. Med. 2006;73:999–1005).

No medication has received approval from the Food and Drug Administration for the treatment of any neuropsychiatric consequence of mTBI, but antidepressant therapy has been shown to improve mood and, potentially, cognitive performance in these patients.

In a 2001 study, for example, Dr. Fann and colleagues conducted an 8-week, nonrandomized, single-blind, placebo run-in trial of sertraline in a group of 15 patients with mTBI and depression.

The investigators conducted neuropsychological testing before and after the treatment trial. Compared with baseline, depression scores improved significantly, as did measures of psychomotor speed, recent verbal memory, recent visual memory, and general cognitive efficacy improved with treatment, the authors wrote.

When pharmacotherapy is considered in this population, it is essential to start medications at low doses and to titrate slowly because of the potential susceptibility to adverse cognitive effects, Dr. Ashman said.

It is best to avoid medications that are highly sedative and those that have deleterious effects on the central nervous system, she noted.

Finally, education is a key component of depression management in mTBI. Education after mTBI for the patient as well as family, friends, employers, and others, should begin early and include an explanation of the range of possible symptoms, the usual time course for resolution, and the potential for long-term problems, according Dr. David B. Arciniegas of the University of Colorado, Denver.

Also, “the clinician should offer validation of the person's experience of symptoms,” and couple the validation with the development of realistic goals aimed at returning to normal activities, he said.

PERSPECTIVE

Until recently, mild traumatic brain injury was presumed to be not very important for generating long-term symptoms or problems. In fact, this consideration was a huge source of contention among those who granted disability status of patients with mild TBI.

Also, disagreement prevailed within legal circles about various injury-related lawsuits, as most companies did not want to pay for the post-mTBI headaches, symptoms of depression, insomnia, and so forth.

Similarly, mTBI has been underconsidered as a source of psychiatric symptoms among mental health clinicians. Few psychiatrists routinely ask patients about mTBI.

This mind-set might be exacerbated by the fact that when there is no loss of consciousness associated with a head injury, individuals often don't seek medical care, and by the measures used to gauge the severity of head trauma and the nomenclature used to describe it.

The term “mild” with respect to traumatic brain injury does not reflect the severity of the injury, but rather the length of time the individual experiences postinjury confusion or disorientation.

On the Glasgow Coma Scale, an injury causing less than 30 minutes of altered consciousness is deemed mild. To patients, families, and even clinicians, that connotation might minimize the awareness of the potential for long-term symptoms.

Since neuroimaging has become more readily available and the science has become more specific, mTBI and the possibility of postinjury symptoms have recently gained more traction. But there is still no way to show cause and effect between mTBI and the broad range of neuropsychiatric symptoms that have been attributed to it.

Until research catches up with reality, the best way to manage psychiatric symptoms in mTBI patients is to first identify such patients through routine history and, educate the patient and family, validate the patient's symptoms, and treat with therapy and medication.

The National Research Council's and Institute of Medicine's recent challenge encouraging the federal government to make the prevention of mental, emotional, and behavioral problems among young people a priority seems daunting. But the challenge can be met.

In recent years, many interventions have shown efficacy in preventing depression, anxiety, conduct disorder, substance abuse, and violence in children and adolescents.

For example, a school-centered substance abuse and violence prevention program developed by the National Center on Addiction and Substance Abuse at Columbia University has seen great success in implementations nationwide.

Called CASASTART (Striving Together to Achieve Rewarding Tomorrows), the intervention promotes communication between children and their families, and collaboration among key community stakeholders.

According to the Substance Abuse and Mental Health Services Administration's national registry of evidence-based practices and programs (NREPP) multiple outcome studies have linked the intervention with significant reductions in participants' risk of drug use and violence as well as improvements in school performance (www.nrepp.samhsa.gov

Another example is an intervention called Coping Cat, developed by Philip C. Kendall, Ph.D., of Temple University in Philadelphia. This intervention uses cognitive-behavioral therapy (CBT) to help children recognize and analyze anxious feelings, and to develop strategies aimed at coping with anxiety-provoking situations. The 16-session program uses behavioral training strategies with demonstrated efficacy.

Studies reported in the NREPP database indicate that the intervention has led to significant decreases in child-reported anxiety symptoms and significant increases in children's coping ability. The effects have been maintained long-term.

Such evidence-based interventions suggest the “the nation is well-positioned to equip young people with the skills and habits needed to live healthy, happy, and productive lives,” said Kenneth E. Warner, Ph.D., dean of the University of Michigan School of Public Health and chair of the Institute of Medicine committee that worked with the National Research Council in writing the new report, “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.” In order to facilitate such outcomes, “we need to develop the systems to deliver effective prevention programs to a far wider group of children and adolescents,” he said.

Toward this end, Internet-based preventive interventions may hold particular promise. Outcome studies of a combined primary care/Web-based program called Project CATCH-IT, developed by Dr. Benjamin W. Van Voorhees of the University of Chicago and his colleagues, have demonstrated the power of the Internet as a medium for preventing depression in at-risk adolescents.

The initial phase of the intervention is a motivational interview conducted by a primary care provider, during which the patient is encouraged to identify his or her goals and to understand the potential impact of depression on attaining those goals. As part of this session, the adolescent is introduced to the Internet-based program, which is made up of multiple modules based on CBT that the user can move through at his or her own pace. The intervention concludes with a follow-up visit with the primary care provider to re-evaluate patient mood and depression risk (http://catchit-public.bsd.uchicago.edu

In a pilot trial of Project CATCH-IT, 14 adolescents who were at high risk for depression experienced favorable changes in depressed mood and symptom scores (Can. Child Adolesc. Psychiatr. Rev. 2005;14:40–3).

More recently, the investigators randomly assigned 84 adolescents at risk for major depression to one of two versions of the intervention. One version consisted of a 1- to 2-minute brief advice component prior to the Project CATCH-IT implementation; the other included the standard 5- to 15-minute motivational interview.

In a comparison of program use and before and after changes and between-group differences for protective and vulnerability factors, both groups substantially engaged the Web site, and both groups experienced declines in Center for Epidemiologic Studies Short Depression Scale (CES-D 10) scores. Also, the percentage of those with clinically significant depression symptoms based on CES-D 10 scores declined significantly in both groups from baseline to week 12, the authors reported (J. Dev. Behav. Pediatr. 2009;30:23–37).

“For clinicians, the results suggest that motivational interviewing and brief advice may both be useful in engaging adolescents with mental health disorders with interventions, and that motivational interviewing may confer an added protective benefit in reducing the incidence of depressive episodes,” the authors wrote.

The development of optimal delivery models offering the best cost/benefit ratio and yielding the most effective results will require “conducting randomized trials comparing varying degrees of face-to-face contact coupled with Internet interventions,” according to the authors. But the advantages of the Internet as a delivery medium over traditional practice are unassailable. Internet applications enable patient autonomy and minimize passive participation, Dr. Van Voorhees said in an interview.

Internet dissemination also does not require scheduling; there is no stigma associated with participation; it is easy to tailor; the fidelity is high; and the application is in vivo, in that the “learning and behavior changes are occurring in the patients' world of activity,” he said.

To be optimally effective, however, Internet interventions must be delivered in the context of a relationship, Dr. Van Voorhees stressed. “This can be as brief as 1–2 primary care meetings to engage the patient, or it could be with a youth minister, coach, or guidance counselor.”

Internet-based interventions will be useful only if the user can read, understand, identify with, and find personal relevance in the program in order to create a goal-directed change plan, Dr. Van Voorhees said. An interesting, media-savvy design with information presented at a 7th-grade reading level would increase the likelihood of adolescent engagement, he noted.

Patients most likely to benefit from this type of intervention are those at moderate risk for mental disorder, Dr. Van Voorhees said.

Despite the obvious benefits of these interventions, they are not immune to challenges. Among the obstacles impeding the transition of these interventions from research to clinical implementation are the lack of a viable commercial distribution model and thus the absence of marketing to build up use of the programs, Dr. Van Voorhees said.

One alternative would be delivery via a government-sponsored public health model, or a mixed government/private pay model, such as that used for vaccine distribution, he said. “Social networking would potentially boost effectiveness, but liability concerns are an issue for institutional sponsors,” he noted.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Perspective

The Internet is one of the greater dissemination tools known to mankind. In many ways, it got us our new president, and if we use it as wisely as he did, we can do many things to improve the public's mental health as per the Institute of Medicine recommendations (See related article on page 2).

It is really simple. If you have an evidence-based strategy delivered via the Internet, such as the CATCH-IT depression intervention, it is easy to put it out to the public to determine whether the efficacy in the pristine academic research environment will be sustained in the real, dirty world.

Internet-based programs are inexpensive and straightforward to facilitate: Develop a Web-based interactive program, put it on the web, publicize the site in the general media, and educate primary care physicians. With the push of a button, the intervention can be disseminated automatically all over the world.

Internet-based prevention interventions also solve the thorny problem of fidelity to the proven model, as the intervention is the same everywhere it goes; you don't have to worry about different practitioners doing the intervention differently. I think of depression prevention interventions that are shown to be evidence based on the Internet as McDonald's, which has a pretty high level of fidelity: You can go any where in the United States, and a McDonald's cheeseburger is going to taste the same.

The key challenge with such interventions is not the delivery mode per se, but the model itself. Does the intervention address protective factors to prevent mental illness in the target population? Is the application user friendly and engaging? If the answers are yes, and there is public and, importantly, government support, the primary barriers to effective implementation have been removed.

Using the Internet as a delivery vehicle also is an advantage because the technology facilitates user-tracking: how often users go to the site, how long they stay there, and so forth. It also offers a great way to monitor process outcomes of the intervention in addition to adding some measures of actual efficacy of the program online.

The National Research Council's and Institute of Medicine's recent challenge encouraging the federal government to make the prevention of mental, emotional, and behavioral problems among young people a priority seems daunting. But the challenge can be met.

In recent years, many interventions have shown efficacy in preventing depression, anxiety, conduct disorder, substance abuse, and violence in children and adolescents.

For example, a school-centered substance abuse and violence prevention program developed by the National Center on Addiction and Substance Abuse at Columbia University has seen great success in implementations nationwide.

Called CASASTART (Striving Together to Achieve Rewarding Tomorrows), the intervention promotes communication between children and their families, and collaboration among key community stakeholders.

According to the Substance Abuse and Mental Health Services Administration's national registry of evidence-based practices and programs (NREPP) multiple outcome studies have linked the intervention with significant reductions in participants' risk of drug use and violence as well as improvements in school performance (www.nrepp.samhsa.gov

Another example is an intervention called Coping Cat, developed by Philip C. Kendall, Ph.D., of Temple University in Philadelphia. This intervention uses cognitive-behavioral therapy (CBT) to help children recognize and analyze anxious feelings, and to develop strategies aimed at coping with anxiety-provoking situations. The 16-session program uses behavioral training strategies with demonstrated efficacy.

Studies reported in the NREPP database indicate that the intervention has led to significant decreases in child-reported anxiety symptoms and significant increases in children's coping ability. The effects have been maintained long-term.

Such evidence-based interventions suggest the “the nation is well-positioned to equip young people with the skills and habits needed to live healthy, happy, and productive lives,” said Kenneth E. Warner, Ph.D., dean of the University of Michigan School of Public Health and chair of the Institute of Medicine committee that worked with the National Research Council in writing the new report, “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.” In order to facilitate such outcomes, “we need to develop the systems to deliver effective prevention programs to a far wider group of children and adolescents,” he said.

Toward this end, Internet-based preventive interventions may hold particular promise. Outcome studies of a combined primary care/Web-based program called Project CATCH-IT, developed by Dr. Benjamin W. Van Voorhees of the University of Chicago and his colleagues, have demonstrated the power of the Internet as a medium for preventing depression in at-risk adolescents.

The initial phase of the intervention is a motivational interview conducted by a primary care provider, during which the patient is encouraged to identify his or her goals and to understand the potential impact of depression on attaining those goals. As part of this session, the adolescent is introduced to the Internet-based program, which is made up of multiple modules based on CBT that the user can move through at his or her own pace. The intervention concludes with a follow-up visit with the primary care provider to re-evaluate patient mood and depression risk (http://catchit-public.bsd.uchicago.edu

In a pilot trial of Project CATCH-IT, 14 adolescents who were at high risk for depression experienced favorable changes in depressed mood and symptom scores (Can. Child Adolesc. Psychiatr. Rev. 2005;14:40–3).

More recently, the investigators randomly assigned 84 adolescents at risk for major depression to one of two versions of the intervention. One version consisted of a 1- to 2-minute brief advice component prior to the Project CATCH-IT implementation; the other included the standard 5- to 15-minute motivational interview.

In a comparison of program use and before and after changes and between-group differences for protective and vulnerability factors, both groups substantially engaged the Web site, and both groups experienced declines in Center for Epidemiologic Studies Short Depression Scale (CES-D 10) scores. Also, the percentage of those with clinically significant depression symptoms based on CES-D 10 scores declined significantly in both groups from baseline to week 12, the authors reported (J. Dev. Behav. Pediatr. 2009;30:23–37).

“For clinicians, the results suggest that motivational interviewing and brief advice may both be useful in engaging adolescents with mental health disorders with interventions, and that motivational interviewing may confer an added protective benefit in reducing the incidence of depressive episodes,” the authors wrote.

The development of optimal delivery models offering the best cost/benefit ratio and yielding the most effective results will require “conducting randomized trials comparing varying degrees of face-to-face contact coupled with Internet interventions,” according to the authors. But the advantages of the Internet as a delivery medium over traditional practice are unassailable. Internet applications enable patient autonomy and minimize passive participation, Dr. Van Voorhees said in an interview.

Internet dissemination also does not require scheduling; there is no stigma associated with participation; it is easy to tailor; the fidelity is high; and the application is in vivo, in that the “learning and behavior changes are occurring in the patients' world of activity,” he said.

To be optimally effective, however, Internet interventions must be delivered in the context of a relationship, Dr. Van Voorhees stressed. “This can be as brief as 1–2 primary care meetings to engage the patient, or it could be with a youth minister, coach, or guidance counselor.”

Internet-based interventions will be useful only if the user can read, understand, identify with, and find personal relevance in the program in order to create a goal-directed change plan, Dr. Van Voorhees said. An interesting, media-savvy design with information presented at a 7th-grade reading level would increase the likelihood of adolescent engagement, he noted.

Patients most likely to benefit from this type of intervention are those at moderate risk for mental disorder, Dr. Van Voorhees said.

Despite the obvious benefits of these interventions, they are not immune to challenges. Among the obstacles impeding the transition of these interventions from research to clinical implementation are the lack of a viable commercial distribution model and thus the absence of marketing to build up use of the programs, Dr. Van Voorhees said.

One alternative would be delivery via a government-sponsored public health model, or a mixed government/private pay model, such as that used for vaccine distribution, he said. “Social networking would potentially boost effectiveness, but liability concerns are an issue for institutional sponsors,” he noted.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Perspective

The Internet is one of the greater dissemination tools known to mankind. In many ways, it got us our new president, and if we use it as wisely as he did, we can do many things to improve the public's mental health as per the Institute of Medicine recommendations (See related article on page 2).

It is really simple. If you have an evidence-based strategy delivered via the Internet, such as the CATCH-IT depression intervention, it is easy to put it out to the public to determine whether the efficacy in the pristine academic research environment will be sustained in the real, dirty world.

Internet-based programs are inexpensive and straightforward to facilitate: Develop a Web-based interactive program, put it on the web, publicize the site in the general media, and educate primary care physicians. With the push of a button, the intervention can be disseminated automatically all over the world.

Internet-based prevention interventions also solve the thorny problem of fidelity to the proven model, as the intervention is the same everywhere it goes; you don't have to worry about different practitioners doing the intervention differently. I think of depression prevention interventions that are shown to be evidence based on the Internet as McDonald's, which has a pretty high level of fidelity: You can go any where in the United States, and a McDonald's cheeseburger is going to taste the same.

The key challenge with such interventions is not the delivery mode per se, but the model itself. Does the intervention address protective factors to prevent mental illness in the target population? Is the application user friendly and engaging? If the answers are yes, and there is public and, importantly, government support, the primary barriers to effective implementation have been removed.

Using the Internet as a delivery vehicle also is an advantage because the technology facilitates user-tracking: how often users go to the site, how long they stay there, and so forth. It also offers a great way to monitor process outcomes of the intervention in addition to adding some measures of actual efficacy of the program online.

The National Research Council's and Institute of Medicine's recent challenge encouraging the federal government to make the prevention of mental, emotional, and behavioral problems among young people a priority seems daunting. But the challenge can be met.

In recent years, many interventions have shown efficacy in preventing depression, anxiety, conduct disorder, substance abuse, and violence in children and adolescents.

For example, a school-centered substance abuse and violence prevention program developed by the National Center on Addiction and Substance Abuse at Columbia University has seen great success in implementations nationwide.

Called CASASTART (Striving Together to Achieve Rewarding Tomorrows), the intervention promotes communication between children and their families, and collaboration among key community stakeholders.

According to the Substance Abuse and Mental Health Services Administration's national registry of evidence-based practices and programs (NREPP) multiple outcome studies have linked the intervention with significant reductions in participants' risk of drug use and violence as well as improvements in school performance (www.nrepp.samhsa.gov

Another example is an intervention called Coping Cat, developed by Philip C. Kendall, Ph.D., of Temple University in Philadelphia. This intervention uses cognitive-behavioral therapy (CBT) to help children recognize and analyze anxious feelings, and to develop strategies aimed at coping with anxiety-provoking situations. The 16-session program uses behavioral training strategies with demonstrated efficacy.

Studies reported in the NREPP database indicate that the intervention has led to significant decreases in child-reported anxiety symptoms and significant increases in children's coping ability. The effects have been maintained long-term.

Such evidence-based interventions suggest the “the nation is well-positioned to equip young people with the skills and habits needed to live healthy, happy, and productive lives,” said Kenneth E. Warner, Ph.D., dean of the University of Michigan School of Public Health and chair of the Institute of Medicine committee that worked with the National Research Council in writing the new report, “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.” In order to facilitate such outcomes, “we need to develop the systems to deliver effective prevention programs to a far wider group of children and adolescents,” he said.

Toward this end, Internet-based preventive interventions may hold particular promise. Outcome studies of a combined primary care/Web-based program called Project CATCH-IT, developed by Dr. Benjamin W. Van Voorhees of the University of Chicago and his colleagues, have demonstrated the power of the Internet as a medium for preventing depression in at-risk adolescents.

The initial phase of the intervention is a motivational interview conducted by a primary care provider, during which the patient is encouraged to identify his or her goals and to understand the potential impact of depression on attaining those goals. As part of this session, the adolescent is introduced to the Internet-based program, which is made up of multiple modules based on CBT that the user can move through at his or her own pace. The intervention concludes with a follow-up visit with the primary care provider to re-evaluate patient mood and depression risk (http://catchit-public.bsd.uchicago.edu

In a pilot trial of Project CATCH-IT, 14 adolescents who were at high risk for depression experienced favorable changes in depressed mood and symptom scores (Can. Child Adolesc. Psychiatr. Rev. 2005;14:40–3).

More recently, the investigators randomly assigned 84 adolescents at risk for major depression to one of two versions of the intervention. One version consisted of a 1- to 2-minute brief advice component prior to the Project CATCH-IT implementation; the other included the standard 5- to 15-minute motivational interview.

In a comparison of program use and before and after changes and between-group differences for protective and vulnerability factors, both groups substantially engaged the Web site, and both groups experienced declines in Center for Epidemiologic Studies Short Depression Scale (CES-D 10) scores. Also, the percentage of those with clinically significant depression symptoms based on CES-D 10 scores declined significantly in both groups from baseline to week 12, the authors reported (J. Dev. Behav. Pediatr. 2009;30:23–37).

“For clinicians, the results suggest that motivational interviewing and brief advice may both be useful in engaging adolescents with mental health disorders with interventions, and that motivational interviewing may confer an added protective benefit in reducing the incidence of depressive episodes,” the authors wrote.

The development of optimal delivery models offering the best cost/benefit ratio and yielding the most effective results will require “conducting randomized trials comparing varying degrees of face-to-face contact coupled with Internet interventions,” according to the authors. But the advantages of the Internet as a delivery medium over traditional practice are unassailable. Internet applications enable patient autonomy and minimize passive participation, Dr. Van Voorhees said in an interview.

Internet dissemination also does not require scheduling; there is no stigma associated with participation; it is easy to tailor; the fidelity is high; and the application is in vivo, in that the “learning and behavior changes are occurring in the patients' world of activity,” he said.

To be optimally effective, however, Internet interventions must be delivered in the context of a relationship, Dr. Van Voorhees stressed. “This can be as brief as 1–2 primary care meetings to engage the patient, or it could be with a youth minister, coach, or guidance counselor.”

Internet-based interventions will be useful only if the user can read, understand, identify with, and find personal relevance in the program in order to create a goal-directed change plan, Dr. Van Voorhees said. An interesting, media-savvy design with information presented at a 7th-grade reading level would increase the likelihood of adolescent engagement, he noted.

Patients most likely to benefit from this type of intervention are those at moderate risk for mental disorder, Dr. Van Voorhees said.

Despite the obvious benefits of these interventions, they are not immune to challenges. Among the obstacles impeding the transition of these interventions from research to clinical implementation are the lack of a viable commercial distribution model and thus the absence of marketing to build up use of the programs, Dr. Van Voorhees said.

One alternative would be delivery via a government-sponsored public health model, or a mixed government/private pay model, such as that used for vaccine distribution, he said. “Social networking would potentially boost effectiveness, but liability concerns are an issue for institutional sponsors,” he noted.

By Diana Mahoney. Share your thoughts and suggestions at cpnews@elsevier.com

Perspective

The Internet is one of the greater dissemination tools known to mankind. In many ways, it got us our new president, and if we use it as wisely as he did, we can do many things to improve the public's mental health as per the Institute of Medicine recommendations (See related article on page 2).

It is really simple. If you have an evidence-based strategy delivered via the Internet, such as the CATCH-IT depression intervention, it is easy to put it out to the public to determine whether the efficacy in the pristine academic research environment will be sustained in the real, dirty world.

Internet-based programs are inexpensive and straightforward to facilitate: Develop a Web-based interactive program, put it on the web, publicize the site in the general media, and educate primary care physicians. With the push of a button, the intervention can be disseminated automatically all over the world.

Internet-based prevention interventions also solve the thorny problem of fidelity to the proven model, as the intervention is the same everywhere it goes; you don't have to worry about different practitioners doing the intervention differently. I think of depression prevention interventions that are shown to be evidence based on the Internet as McDonald's, which has a pretty high level of fidelity: You can go any where in the United States, and a McDonald's cheeseburger is going to taste the same.

The key challenge with such interventions is not the delivery mode per se, but the model itself. Does the intervention address protective factors to prevent mental illness in the target population? Is the application user friendly and engaging? If the answers are yes, and there is public and, importantly, government support, the primary barriers to effective implementation have been removed.

Using the Internet as a delivery vehicle also is an advantage because the technology facilitates user-tracking: how often users go to the site, how long they stay there, and so forth. It also offers a great way to monitor process outcomes of the intervention in addition to adding some measures of actual efficacy of the program online.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Psychiatric rehabilitation is an important but often overlooked component of managing–and sometimes preventing–prodromal schizophrenia symptoms.

However, symptom control and relapse prevention should not be confused with recovery. Studies have shown that, even with optimal drug therapy and remission of symptoms, functional recovery in early psychosis is poor.

For example, in a 2004 study involving 118 patients in their first episode of schizophrenia or schizoaffective disorder who were treated based on a standard medication algorithm, about 47% achieved remission of symptoms after 5 years, but less than 14% met full recovery criteria–defined as symptom remission and adequate social/vocational functioning–for 2 years or longer (Am. J. Psychiatry 2004;161:473-9).

Similar results were observed in the McLean-Harvard First Episode Project, which recruited 257 patients with affective and nonaffective psychosis at their first lifetime psychiatric hospitalization, conducted baseline and 6-month follow-up evaluations, and assessed syndromal and functional status at follow-up.

Recovery outcomes were syndromal status, defined as the absence of DSM-IV criteria for a current episode, and functional status, as measured by vocational and residential functioning. Although syndromal recovery was achieved by nearly half of patients within 3 months of hospitalization, functional recovery was not achieved by 6 months in nearly two-thirds of patients who had attained syndromal recovery, according to the authors (Biol. Psychiatry 2000;48:467-76).

The available literature overwhelmingly suggests that a pure symptomatic remission does not predict functional recovery, and that failing to pay due attention to social and occupational considerations in early psychosis can contribute to a worse long-term prognosis.

“A remission is a necessity but not a sufficient prerequisite for recovery,” according to Dr. Georg Juckel of Ruhr University Bochum (Germany) and Dr. Pier Luigi Morosini of the Italian National Institute of Health in Rome, who stressed in a recent review article that psychosocial functioning should be the treatment outcome criterion in schizophrenia.

“The improvement of symptoms is not sufficient to reach this difficult treatment goal. The deciding factor is how well the patient is able to fulfill private and professional requirements. Ideally, the treatment has to improve the social functioning in such a way that the patient is able to achieve reintegration and a major improvement in the quality of life” (Curr. Opin. Psychiatry 2008; 21:630-9).

Toward this end, psychiatric rehabilitation, in addition to medication, should be a major player in the field of schizophrenia management. By definition, psychiatric rehabilitation in schizophrenia involves the use of psychosocial interventions to minimize symptoms and the possibility of relapse while maximizing social and vocational functioning.

Without the inclusion of psychiatric rehabilitation interventions, according to William Anthony, Ph.D., of the Center for Psychiatric Rehabilitation at Boston University, “people who are at risk of developing long-term, severe mental illnesses will not receive the critical help they need to remain in, resume, or improve their living, learning, working, and social roles.”

In a recent editorial, Dr. Anthony advocated for “the integration of contributions of psychiatric rehabilitation into current research and practice in the area of severe mental illness,” stressing that “we should not have to learn over again in the field of prevention what has taken us so long to learn in the treatment field–that medications and therapies designed to ameliorate symptoms do not routinely or singularly help people achieve their residential, educational, vocational, or social goals” (Psychiatr. Serv. 2009;60:3).

A 2008 initiative from the National Institute of Mental Health (NIMH) provides a step in this direction. Recovery After an Initial Schizophrenic Episode (RAISE) seeks to “fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness,” said Dr. John K. Hsiao of the organization's division of services and interventions research. The specific aims of the initiative include these:

▸ The development of a comprehensive, integrated treatment intervention for promoting symptom recovery, minimizing disability, and maximizing social, academic, and vocational functioning.

▸ The evaluation of the intervention's feasibility and practical implementation in the community.

▸ The assessment of the intervention's overall clinical impact and cost-effectiveness relative to current treatment standards.

Since antipsychotic drugs “are not able to restore skills and abilities lost to the illness,” said Dr. Hsiao, “the important unanswered question is whether function could be preserved and disability forestalled after an initial schizophrenic episode by intense and sustained pharmacological, psychosocial, and rehabilitative intervention.”

Preliminary findings from a study by Evan J. Waldheter and colleagues at the University of North Carolina at Chapel Hill suggest the answer to that question might be yes. The investigators have developed a manualized, comprehensive cognitive-behavioral therapy program for people recovering from an initial episode of nonaffective psychosis called the Graduated Recovery Intervention Program (GRIP).

The objective of the program, which is delivered by a multidisciplinary treatment team and comprises four phases focusing on engagement and wellness management, substance use, persistent symptoms, and functional recovery, “is to improve occupational functioning and promote goal pursuit and effective illness self-management,” the authors reported (Community Mental Health J. 2008;44:443-55).

In an open feasibility trial, 10 individuals recovering from an initial psychotic episode were assigned to receive treatment as usual plus GRIP for up to 36 weeks, and completed baseline and post-treatment assessments. Social functioning was the primary clinical outcome of the study, and symptoms, personal goal attainment, attitudes toward antipsychotic medication, and substance use were secondary outcomes.

Overall, study participants attended a mean of 15 sessions. Among participants who attended at least 12 sessions, “GRIP was associated with improvements in almost all measured domains, especially social functioning, positive and general symptoms, and goal attainment,” the authors wrote. Early treatment termination, on the other hand, “was associated with deterioration in almost all domains.”

In terms of qualitative feedback, “both therapists and participants reported positive experiences,” they said.

Although the study's small sample size and uncontrolled design limit definitive conclusions, “the preliminary results suggest that GRIP may be associated with clinical benefits, can assist clients in pursuing their personal goals, and is generally well received by clients and therapists,” according to the authors.

Taken together, the available data support the inclusion of functional recovery as a goal of schizophrenia management, according to Philip D. Harvey, Ph.D., of Emory University, Atlanta, and his colleagues. Although the primary focus for the management of schizophrenia has historically been on clinical symptoms and their consequences, this does not address most of the problems faced by schizophrenia patients, they wrote (Schizophr. Bull. 2009 Jan. 6 [doi:10.1093/schbul/sbn171]). “We see functional remission as a separate domain of functioning from clinical remission and subjective response and argue that the process of recovery includes all of these domains.”

Perspective

Schizophrenia is a devastating illness, and one of its hallmarks is also one of the most stubborn obstacles to effective management: a structural deficit that limits the brain's capacity for insight.

Without insight into the illness, individuals with schizophrenia often deny they have a disease, which in turn leads to an unwillingness to buy into treatment, whether medication or behavioral therapy. This is especially true with a first episode. Without multiple psychotic breaks, these individuals cannot see the patterns that might be suggestive of the disease.

Another challenge is the difficulty of determining the exact nature of a first break: Was it a first schizophrenic episode? Was it a drug-induced episode? To some extent, this has been solved with the identification of the unique nature of prodromal schizophrenia symptoms: magical thinking, anxiety, delusions, and hallucinations–although such symptoms can occur in many different illnesses.

Fortunately, you don't need to know how a fire started before you can put it out. The first step toward putting out the schizophrenia fire–after convincing the patient that he or she has a major psychiatric disorder–is medication, because without it, there almost certainly will be a relapse. But relapse prevention should not be confused with recovery. The individual still has an active form of schizophrenia. So, while medication is a necessary component to treatment management, it might not be the most important, as behavior is multidetermined and treatment is interdependent.

Successful management requires family support to provide external compensation for the lack of insight; a structured, individual intervention that the patient can understand and practice; and assertive case management to oversee all elements of care and compliance.

Cognitive-behavioral approaches are beneficial in that they are structured and manualized with clear expectations. Another benefit is the capacity to develop the ability to identify when a symptom begins, which puts patients in a better position to respond to the symptom vs. reacting to it.

The hope is that with these self-observations and empowering techniques, patients will be more willing to continue therapy, and by so doing progress along a normal path in their lives.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Psychiatric rehabilitation is an important but often overlooked component of managing–and sometimes preventing–prodromal schizophrenia symptoms.

However, symptom control and relapse prevention should not be confused with recovery. Studies have shown that, even with optimal drug therapy and remission of symptoms, functional recovery in early psychosis is poor.

For example, in a 2004 study involving 118 patients in their first episode of schizophrenia or schizoaffective disorder who were treated based on a standard medication algorithm, about 47% achieved remission of symptoms after 5 years, but less than 14% met full recovery criteria–defined as symptom remission and adequate social/vocational functioning–for 2 years or longer (Am. J. Psychiatry 2004;161:473-9).

Similar results were observed in the McLean-Harvard First Episode Project, which recruited 257 patients with affective and nonaffective psychosis at their first lifetime psychiatric hospitalization, conducted baseline and 6-month follow-up evaluations, and assessed syndromal and functional status at follow-up.

Recovery outcomes were syndromal status, defined as the absence of DSM-IV criteria for a current episode, and functional status, as measured by vocational and residential functioning. Although syndromal recovery was achieved by nearly half of patients within 3 months of hospitalization, functional recovery was not achieved by 6 months in nearly two-thirds of patients who had attained syndromal recovery, according to the authors (Biol. Psychiatry 2000;48:467-76).

The available literature overwhelmingly suggests that a pure symptomatic remission does not predict functional recovery, and that failing to pay due attention to social and occupational considerations in early psychosis can contribute to a worse long-term prognosis.

“A remission is a necessity but not a sufficient prerequisite for recovery,” according to Dr. Georg Juckel of Ruhr University Bochum (Germany) and Dr. Pier Luigi Morosini of the Italian National Institute of Health in Rome, who stressed in a recent review article that psychosocial functioning should be the treatment outcome criterion in schizophrenia.

“The improvement of symptoms is not sufficient to reach this difficult treatment goal. The deciding factor is how well the patient is able to fulfill private and professional requirements. Ideally, the treatment has to improve the social functioning in such a way that the patient is able to achieve reintegration and a major improvement in the quality of life” (Curr. Opin. Psychiatry 2008; 21:630-9).

Toward this end, psychiatric rehabilitation, in addition to medication, should be a major player in the field of schizophrenia management. By definition, psychiatric rehabilitation in schizophrenia involves the use of psychosocial interventions to minimize symptoms and the possibility of relapse while maximizing social and vocational functioning.

Without the inclusion of psychiatric rehabilitation interventions, according to William Anthony, Ph.D., of the Center for Psychiatric Rehabilitation at Boston University, “people who are at risk of developing long-term, severe mental illnesses will not receive the critical help they need to remain in, resume, or improve their living, learning, working, and social roles.”

In a recent editorial, Dr. Anthony advocated for “the integration of contributions of psychiatric rehabilitation into current research and practice in the area of severe mental illness,” stressing that “we should not have to learn over again in the field of prevention what has taken us so long to learn in the treatment field–that medications and therapies designed to ameliorate symptoms do not routinely or singularly help people achieve their residential, educational, vocational, or social goals” (Psychiatr. Serv. 2009;60:3).

A 2008 initiative from the National Institute of Mental Health (NIMH) provides a step in this direction. Recovery After an Initial Schizophrenic Episode (RAISE) seeks to “fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness,” said Dr. John K. Hsiao of the organization's division of services and interventions research. The specific aims of the initiative include these:

▸ The development of a comprehensive, integrated treatment intervention for promoting symptom recovery, minimizing disability, and maximizing social, academic, and vocational functioning.

▸ The evaluation of the intervention's feasibility and practical implementation in the community.

▸ The assessment of the intervention's overall clinical impact and cost-effectiveness relative to current treatment standards.

Since antipsychotic drugs “are not able to restore skills and abilities lost to the illness,” said Dr. Hsiao, “the important unanswered question is whether function could be preserved and disability forestalled after an initial schizophrenic episode by intense and sustained pharmacological, psychosocial, and rehabilitative intervention.”

Preliminary findings from a study by Evan J. Waldheter and colleagues at the University of North Carolina at Chapel Hill suggest the answer to that question might be yes. The investigators have developed a manualized, comprehensive cognitive-behavioral therapy program for people recovering from an initial episode of nonaffective psychosis called the Graduated Recovery Intervention Program (GRIP).

The objective of the program, which is delivered by a multidisciplinary treatment team and comprises four phases focusing on engagement and wellness management, substance use, persistent symptoms, and functional recovery, “is to improve occupational functioning and promote goal pursuit and effective illness self-management,” the authors reported (Community Mental Health J. 2008;44:443-55).

In an open feasibility trial, 10 individuals recovering from an initial psychotic episode were assigned to receive treatment as usual plus GRIP for up to 36 weeks, and completed baseline and post-treatment assessments. Social functioning was the primary clinical outcome of the study, and symptoms, personal goal attainment, attitudes toward antipsychotic medication, and substance use were secondary outcomes.

Overall, study participants attended a mean of 15 sessions. Among participants who attended at least 12 sessions, “GRIP was associated with improvements in almost all measured domains, especially social functioning, positive and general symptoms, and goal attainment,” the authors wrote. Early treatment termination, on the other hand, “was associated with deterioration in almost all domains.”

In terms of qualitative feedback, “both therapists and participants reported positive experiences,” they said.

Although the study's small sample size and uncontrolled design limit definitive conclusions, “the preliminary results suggest that GRIP may be associated with clinical benefits, can assist clients in pursuing their personal goals, and is generally well received by clients and therapists,” according to the authors.

Taken together, the available data support the inclusion of functional recovery as a goal of schizophrenia management, according to Philip D. Harvey, Ph.D., of Emory University, Atlanta, and his colleagues. Although the primary focus for the management of schizophrenia has historically been on clinical symptoms and their consequences, this does not address most of the problems faced by schizophrenia patients, they wrote (Schizophr. Bull. 2009 Jan. 6 [doi:10.1093/schbul/sbn171]). “We see functional remission as a separate domain of functioning from clinical remission and subjective response and argue that the process of recovery includes all of these domains.”

Perspective

Schizophrenia is a devastating illness, and one of its hallmarks is also one of the most stubborn obstacles to effective management: a structural deficit that limits the brain's capacity for insight.

Without insight into the illness, individuals with schizophrenia often deny they have a disease, which in turn leads to an unwillingness to buy into treatment, whether medication or behavioral therapy. This is especially true with a first episode. Without multiple psychotic breaks, these individuals cannot see the patterns that might be suggestive of the disease.

Another challenge is the difficulty of determining the exact nature of a first break: Was it a first schizophrenic episode? Was it a drug-induced episode? To some extent, this has been solved with the identification of the unique nature of prodromal schizophrenia symptoms: magical thinking, anxiety, delusions, and hallucinations–although such symptoms can occur in many different illnesses.

Fortunately, you don't need to know how a fire started before you can put it out. The first step toward putting out the schizophrenia fire–after convincing the patient that he or she has a major psychiatric disorder–is medication, because without it, there almost certainly will be a relapse. But relapse prevention should not be confused with recovery. The individual still has an active form of schizophrenia. So, while medication is a necessary component to treatment management, it might not be the most important, as behavior is multidetermined and treatment is interdependent.

Successful management requires family support to provide external compensation for the lack of insight; a structured, individual intervention that the patient can understand and practice; and assertive case management to oversee all elements of care and compliance.

Cognitive-behavioral approaches are beneficial in that they are structured and manualized with clear expectations. Another benefit is the capacity to develop the ability to identify when a symptom begins, which puts patients in a better position to respond to the symptom vs. reacting to it.

The hope is that with these self-observations and empowering techniques, patients will be more willing to continue therapy, and by so doing progress along a normal path in their lives.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Psychiatric rehabilitation is an important but often overlooked component of managing–and sometimes preventing–prodromal schizophrenia symptoms.

However, symptom control and relapse prevention should not be confused with recovery. Studies have shown that, even with optimal drug therapy and remission of symptoms, functional recovery in early psychosis is poor.

For example, in a 2004 study involving 118 patients in their first episode of schizophrenia or schizoaffective disorder who were treated based on a standard medication algorithm, about 47% achieved remission of symptoms after 5 years, but less than 14% met full recovery criteria–defined as symptom remission and adequate social/vocational functioning–for 2 years or longer (Am. J. Psychiatry 2004;161:473-9).

Similar results were observed in the McLean-Harvard First Episode Project, which recruited 257 patients with affective and nonaffective psychosis at their first lifetime psychiatric hospitalization, conducted baseline and 6-month follow-up evaluations, and assessed syndromal and functional status at follow-up.

Recovery outcomes were syndromal status, defined as the absence of DSM-IV criteria for a current episode, and functional status, as measured by vocational and residential functioning. Although syndromal recovery was achieved by nearly half of patients within 3 months of hospitalization, functional recovery was not achieved by 6 months in nearly two-thirds of patients who had attained syndromal recovery, according to the authors (Biol. Psychiatry 2000;48:467-76).

The available literature overwhelmingly suggests that a pure symptomatic remission does not predict functional recovery, and that failing to pay due attention to social and occupational considerations in early psychosis can contribute to a worse long-term prognosis.

“A remission is a necessity but not a sufficient prerequisite for recovery,” according to Dr. Georg Juckel of Ruhr University Bochum (Germany) and Dr. Pier Luigi Morosini of the Italian National Institute of Health in Rome, who stressed in a recent review article that psychosocial functioning should be the treatment outcome criterion in schizophrenia.

“The improvement of symptoms is not sufficient to reach this difficult treatment goal. The deciding factor is how well the patient is able to fulfill private and professional requirements. Ideally, the treatment has to improve the social functioning in such a way that the patient is able to achieve reintegration and a major improvement in the quality of life” (Curr. Opin. Psychiatry 2008; 21:630-9).

Toward this end, psychiatric rehabilitation, in addition to medication, should be a major player in the field of schizophrenia management. By definition, psychiatric rehabilitation in schizophrenia involves the use of psychosocial interventions to minimize symptoms and the possibility of relapse while maximizing social and vocational functioning.

Without the inclusion of psychiatric rehabilitation interventions, according to William Anthony, Ph.D., of the Center for Psychiatric Rehabilitation at Boston University, “people who are at risk of developing long-term, severe mental illnesses will not receive the critical help they need to remain in, resume, or improve their living, learning, working, and social roles.”

In a recent editorial, Dr. Anthony advocated for “the integration of contributions of psychiatric rehabilitation into current research and practice in the area of severe mental illness,” stressing that “we should not have to learn over again in the field of prevention what has taken us so long to learn in the treatment field–that medications and therapies designed to ameliorate symptoms do not routinely or singularly help people achieve their residential, educational, vocational, or social goals” (Psychiatr. Serv. 2009;60:3).

A 2008 initiative from the National Institute of Mental Health (NIMH) provides a step in this direction. Recovery After an Initial Schizophrenic Episode (RAISE) seeks to “fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness,” said Dr. John K. Hsiao of the organization's division of services and interventions research. The specific aims of the initiative include these:

▸ The development of a comprehensive, integrated treatment intervention for promoting symptom recovery, minimizing disability, and maximizing social, academic, and vocational functioning.

▸ The evaluation of the intervention's feasibility and practical implementation in the community.

▸ The assessment of the intervention's overall clinical impact and cost-effectiveness relative to current treatment standards.

Since antipsychotic drugs “are not able to restore skills and abilities lost to the illness,” said Dr. Hsiao, “the important unanswered question is whether function could be preserved and disability forestalled after an initial schizophrenic episode by intense and sustained pharmacological, psychosocial, and rehabilitative intervention.”

Preliminary findings from a study by Evan J. Waldheter and colleagues at the University of North Carolina at Chapel Hill suggest the answer to that question might be yes. The investigators have developed a manualized, comprehensive cognitive-behavioral therapy program for people recovering from an initial episode of nonaffective psychosis called the Graduated Recovery Intervention Program (GRIP).

The objective of the program, which is delivered by a multidisciplinary treatment team and comprises four phases focusing on engagement and wellness management, substance use, persistent symptoms, and functional recovery, “is to improve occupational functioning and promote goal pursuit and effective illness self-management,” the authors reported (Community Mental Health J. 2008;44:443-55).

In an open feasibility trial, 10 individuals recovering from an initial psychotic episode were assigned to receive treatment as usual plus GRIP for up to 36 weeks, and completed baseline and post-treatment assessments. Social functioning was the primary clinical outcome of the study, and symptoms, personal goal attainment, attitudes toward antipsychotic medication, and substance use were secondary outcomes.

Overall, study participants attended a mean of 15 sessions. Among participants who attended at least 12 sessions, “GRIP was associated with improvements in almost all measured domains, especially social functioning, positive and general symptoms, and goal attainment,” the authors wrote. Early treatment termination, on the other hand, “was associated with deterioration in almost all domains.”

In terms of qualitative feedback, “both therapists and participants reported positive experiences,” they said.

Although the study's small sample size and uncontrolled design limit definitive conclusions, “the preliminary results suggest that GRIP may be associated with clinical benefits, can assist clients in pursuing their personal goals, and is generally well received by clients and therapists,” according to the authors.

Taken together, the available data support the inclusion of functional recovery as a goal of schizophrenia management, according to Philip D. Harvey, Ph.D., of Emory University, Atlanta, and his colleagues. Although the primary focus for the management of schizophrenia has historically been on clinical symptoms and their consequences, this does not address most of the problems faced by schizophrenia patients, they wrote (Schizophr. Bull. 2009 Jan. 6 [doi:10.1093/schbul/sbn171]). “We see functional remission as a separate domain of functioning from clinical remission and subjective response and argue that the process of recovery includes all of these domains.”

Perspective

Schizophrenia is a devastating illness, and one of its hallmarks is also one of the most stubborn obstacles to effective management: a structural deficit that limits the brain's capacity for insight.

Without insight into the illness, individuals with schizophrenia often deny they have a disease, which in turn leads to an unwillingness to buy into treatment, whether medication or behavioral therapy. This is especially true with a first episode. Without multiple psychotic breaks, these individuals cannot see the patterns that might be suggestive of the disease.

Another challenge is the difficulty of determining the exact nature of a first break: Was it a first schizophrenic episode? Was it a drug-induced episode? To some extent, this has been solved with the identification of the unique nature of prodromal schizophrenia symptoms: magical thinking, anxiety, delusions, and hallucinations–although such symptoms can occur in many different illnesses.

Fortunately, you don't need to know how a fire started before you can put it out. The first step toward putting out the schizophrenia fire–after convincing the patient that he or she has a major psychiatric disorder–is medication, because without it, there almost certainly will be a relapse. But relapse prevention should not be confused with recovery. The individual still has an active form of schizophrenia. So, while medication is a necessary component to treatment management, it might not be the most important, as behavior is multidetermined and treatment is interdependent.

Successful management requires family support to provide external compensation for the lack of insight; a structured, individual intervention that the patient can understand and practice; and assertive case management to oversee all elements of care and compliance.

Cognitive-behavioral approaches are beneficial in that they are structured and manualized with clear expectations. Another benefit is the capacity to develop the ability to identify when a symptom begins, which puts patients in a better position to respond to the symptom vs. reacting to it.

The hope is that with these self-observations and empowering techniques, patients will be more willing to continue therapy, and by so doing progress along a normal path in their lives.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

The legacy of parental alcoholism cuts deep. Nearly 6.2 million children in the United States younger than 18 years old live with at least one parent who is currently dependent on alcohol, according to estimates from the 1996 National Household Survey on Drug Abuse (NHSDA, now known as the National Survey on Drug Use and Health). The number increases exponentially when it is broadened to include those children living with adults who have abused or been dependent on alcohol some time in their lives.

Research has long established that having an alcoholic parent increases a child's risk for multiple negative behavioral and developmental outcomes. That increased risk is conveyed through social, emotional, environmental, and biologic pathways. In particular, many studies have focused on the rates of alcohol and drug use and abuse among children of alcoholics, and most have similarly concluded that this population is significantly more vulnerable to substance abuse problems than their peers from nonalcoholic families.

Data from a national epidemiologic survey out of Johns Hopkins University, Baltimore, for example, show that children of a parent with active alcohol dependence initiated use of alcohol, cigarettes, and marijuana earlier and at higher age-specific rates than children who did not have an alcohol-dependent parent.

Using NHSDA information collected from 1995 to 1997, the investigators identified a sample of 2,888 parent-child pairs, which included 114 children of alcohol-dependent parents and 2,774 children whose interviewed parent was not dependent on alcohol. The odds ratios for past-year tobacco, alcohol, and marijuana use for the children with alcoholic parents were 3.2, 1.6, and 2.9, respectively.

The differences in substance use between the two groups started to emerge as early as age 9 years, and the additional risk was sustained at least through age 17 years, the authors wrote. By 17 years, 73% the children of alcoholic parents had smoked cigarettes, 70% had begun drinking alcohol, and 41% had smoked marijuana, compared with 44%, 57%, and 26%, respectively, of the children from nonalcoholic homes (Drug Alcohol. Depend. 2001;65:1–8).

In addition to an increased risk for substance use in this population, there also appears to be a greater likelihood of an accelerated trajectory from onset of drinking and drug use to problem substance use, a recent study by Andrea Hussong, Ph.D., of the University of North Carolina, Chapel Hill, and her colleagues shows. Using longitudinal data from a community-based sample, the investigators conducted survival analyses and determined that children of alcoholics progressed more quickly from initial adolescent alcohol use to the onset of disorder than matched controls, even after controlling for externalizing symptoms and heavier drinking patterns at initiation. A similar “telescoping” risk was observed for drug disorders (J. Abnorm. Psychol. 2008;117:63–78).

With respect to illicit drug use, adolescent children of alcoholics who use drugs are more likely to continue doing so during their transition to young adulthood than their peers from nonalcoholic families. In a study that tracked and monitored the drug use habits of 545 adolescent children of alcoholics and demographically matched children of nonalcoholic parents for 15 years, David B. Flora, Ph.D., of the University of North Carolina at Chapel Hill, and his colleagues determined that the control group significantly decreased their drug use during this time, consistent with national data, while the children of alcoholics did not.

The findings show that “[children of alcoholics] do not typically follow the normative trend by which individuals are expected to mature out of drug use before age 30,” the authors wrote (Psychol. Addict. Behav. 2005;19:352–62).

The investigators also looked at the impact of marriage on drug use trajectories in young adult children of alcoholics and determined that “marriage mediated but did not moderate the relations between parental alcoholism and the rate of change in drug use during the transition into young adulthood and the level of drug use at ages 25 to 30.”

Although marriage predicted the amount of drug use in men 25–30 years old–about 94% of married men either remained abstinent from drugs or decreased their drug use–the children of alcoholics in this study were less likely to be married and thus not only had smaller decreases in drug use between 25 and 30, they had higher levels of drug use overall, according to the authors.

In addition to a proclivity for alcohol and drug use and abuse, children of alcoholics are at increased risk for other negative outcomes, including conduct problems, aggression, depression, and anxiety, according to the Substance Abuse and Mental Health Services Administration (SAMSHA).

But not all children of alcoholics succumb to the potential negative consequences. In fact, studies suggest that, despite the odds, a large proportion of children of alcoholics do not develop serious problems.

In an often-cited longitudinal study of children of alcoholics born on the Hawaiian island of Kauai, psychologist Emmy Werner, Ph.D., of the University of California, Davis, reported on 49 children of alcoholic parents who were raised in chronic poverty from birth to 18 years. Although 41% of the study participants had developed coping problems by age 18, 59% appeared to cope well and had not developed serious problems. Among the shared characteristics of the “resilient” children were adequate communication skills, average intelligence, a desire to achieve, and the ability to get positive attention from other people (J. Stud. Alcohol. 1986;47:34–40).

A later report on the same cohort showed that study participants who effectively coped with the trauma of growing up with an alcoholic parent and became competent adults by age 32 had relied on more sources of support in their childhood than did those offspring of alcoholics with coping problems (Subst. Use Misuse 2004; 39:699–720).

In a separate 3-year study of 267 adolescents, including 127 children of alcoholics, self-awareness, a perceived control over one's environment, and the possession of cognitive coping skills were all identified as having a buffering effect against potential negative consequences associated with having an alcoholic parent (J. Stud. Alcohol 1997;58:272–9).

Although resilience in children of alcoholics is still not fully understood–a recent study by the University of Michigan, Ann Arbor, that has identified differences in neural activation mechanisms between vulnerable and resilient children of alcoholic parents adds a new dimension to the research in this arena (Alcohol Clin. Exp. Res. 2008;32:414–26)–the available evidence suggests that building resilience is a critical intervention goal.

For example, in a school-based prevention intervention called Students Together and Resourceful (STAR)–identified as a model program by SAMSHA–children of alcoholics gain self-efficacy through education about alcoholism and its effects on the family as well as group exercises that allow participants to recognize and express their feelings and to practice problem-solving, stress-management, and alcohol-refusal skills. In randomized trials comparing outcomes of children of alcoholics who did and did not participate in the intervention, participants attained improved self-concept as well as decreases in depression (Pediatrics 1999;103:1112–21).

Certain elements of the STAR program should be universal to all interventions for this population, according to lead author James Emshoff, Ph.D., professor of psychology at Georgia State University, Atlanta. These include “skill building in the areas of coping and social competence, social support, an outlet for the safe expression of feelings, and healthy, alternative activities.”

Perspective

Children of alcoholic parents are at risk for negative mental health outcomes. But many overcome the genetic, biologic, and, often, environmental odds that are stacked against them and become competent, mentally healthy adults. Whether innate or acquired, resiliency keeps risk factors from morphing into predictive factors.

Resilient adolescents share several well-defined characteristics. They include:

▸ Curiosity and intellectual mastery.

▸ Compassion, with detachment.

▸ The ability to conceptualize.

▸ The conviction of one's right to survive.

▸ The ability to remember and evoke images of good and sustaining figures.

▸ The ability to be in touch with affects.

▸ A goal to live for support, and the ability to attract and use it.

▸ A vision of the possibility and desirability of restored civilized moral order.

▸ The need and ability to help others.

▸ Resourcefulness.

▸ The capacity to turn traumatic helplessness into learned helpfulness.

Resiliency in at-risk youth can be cultivated. The best way is to strengthen these individuals is through family-based interventions. The most researched family-based intervention is found in the Strong African-American Families (SAAF) program, which increases protective factors that should prevent adolescents from using drugs. Interventions based on this premise also can be useful for children of alcoholics.

The SAAF intervention teaches parents how to communicate with their children in ways that nurture connectedness. The intervention guides parents on how to train their children to be responsive–but not overly reactive–to situations in their lives. The intervention also teaches children how to have a sense of power by resisting peer pressure to use drugs and alcohol.

Some children of alcoholics may be in situations that are not amenable to family-based interventions, in which case society has to provide support in the form of activities that occur out of the family context, through school- or church-based interventions, for example.

Involvement in activities such as sports teams, scouting, music programs, and martial arts training also can help children build a sense of achievement, acceptance, and self-efficacy. Positive role models with whom the children can identify also foster resiliency.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

The legacy of parental alcoholism cuts deep. Nearly 6.2 million children in the United States younger than 18 years old live with at least one parent who is currently dependent on alcohol, according to estimates from the 1996 National Household Survey on Drug Abuse (NHSDA, now known as the National Survey on Drug Use and Health). The number increases exponentially when it is broadened to include those children living with adults who have abused or been dependent on alcohol some time in their lives.

Research has long established that having an alcoholic parent increases a child's risk for multiple negative behavioral and developmental outcomes. That increased risk is conveyed through social, emotional, environmental, and biologic pathways. In particular, many studies have focused on the rates of alcohol and drug use and abuse among children of alcoholics, and most have similarly concluded that this population is significantly more vulnerable to substance abuse problems than their peers from nonalcoholic families.

Data from a national epidemiologic survey out of Johns Hopkins University, Baltimore, for example, show that children of a parent with active alcohol dependence initiated use of alcohol, cigarettes, and marijuana earlier and at higher age-specific rates than children who did not have an alcohol-dependent parent.

Using NHSDA information collected from 1995 to 1997, the investigators identified a sample of 2,888 parent-child pairs, which included 114 children of alcohol-dependent parents and 2,774 children whose interviewed parent was not dependent on alcohol. The odds ratios for past-year tobacco, alcohol, and marijuana use for the children with alcoholic parents were 3.2, 1.6, and 2.9, respectively.

The differences in substance use between the two groups started to emerge as early as age 9 years, and the additional risk was sustained at least through age 17 years, the authors wrote. By 17 years, 73% the children of alcoholic parents had smoked cigarettes, 70% had begun drinking alcohol, and 41% had smoked marijuana, compared with 44%, 57%, and 26%, respectively, of the children from nonalcoholic homes (Drug Alcohol. Depend. 2001;65:1–8).

In addition to an increased risk for substance use in this population, there also appears to be a greater likelihood of an accelerated trajectory from onset of drinking and drug use to problem substance use, a recent study by Andrea Hussong, Ph.D., of the University of North Carolina, Chapel Hill, and her colleagues shows. Using longitudinal data from a community-based sample, the investigators conducted survival analyses and determined that children of alcoholics progressed more quickly from initial adolescent alcohol use to the onset of disorder than matched controls, even after controlling for externalizing symptoms and heavier drinking patterns at initiation. A similar “telescoping” risk was observed for drug disorders (J. Abnorm. Psychol. 2008;117:63–78).

With respect to illicit drug use, adolescent children of alcoholics who use drugs are more likely to continue doing so during their transition to young adulthood than their peers from nonalcoholic families. In a study that tracked and monitored the drug use habits of 545 adolescent children of alcoholics and demographically matched children of nonalcoholic parents for 15 years, David B. Flora, Ph.D., of the University of North Carolina at Chapel Hill, and his colleagues determined that the control group significantly decreased their drug use during this time, consistent with national data, while the children of alcoholics did not.

The findings show that “[children of alcoholics] do not typically follow the normative trend by which individuals are expected to mature out of drug use before age 30,” the authors wrote (Psychol. Addict. Behav. 2005;19:352–62).

The investigators also looked at the impact of marriage on drug use trajectories in young adult children of alcoholics and determined that “marriage mediated but did not moderate the relations between parental alcoholism and the rate of change in drug use during the transition into young adulthood and the level of drug use at ages 25 to 30.”

Although marriage predicted the amount of drug use in men 25–30 years old–about 94% of married men either remained abstinent from drugs or decreased their drug use–the children of alcoholics in this study were less likely to be married and thus not only had smaller decreases in drug use between 25 and 30, they had higher levels of drug use overall, according to the authors.

In addition to a proclivity for alcohol and drug use and abuse, children of alcoholics are at increased risk for other negative outcomes, including conduct problems, aggression, depression, and anxiety, according to the Substance Abuse and Mental Health Services Administration (SAMSHA).

But not all children of alcoholics succumb to the potential negative consequences. In fact, studies suggest that, despite the odds, a large proportion of children of alcoholics do not develop serious problems.

In an often-cited longitudinal study of children of alcoholics born on the Hawaiian island of Kauai, psychologist Emmy Werner, Ph.D., of the University of California, Davis, reported on 49 children of alcoholic parents who were raised in chronic poverty from birth to 18 years. Although 41% of the study participants had developed coping problems by age 18, 59% appeared to cope well and had not developed serious problems. Among the shared characteristics of the “resilient” children were adequate communication skills, average intelligence, a desire to achieve, and the ability to get positive attention from other people (J. Stud. Alcohol. 1986;47:34–40).

A later report on the same cohort showed that study participants who effectively coped with the trauma of growing up with an alcoholic parent and became competent adults by age 32 had relied on more sources of support in their childhood than did those offspring of alcoholics with coping problems (Subst. Use Misuse 2004; 39:699–720).

In a separate 3-year study of 267 adolescents, including 127 children of alcoholics, self-awareness, a perceived control over one's environment, and the possession of cognitive coping skills were all identified as having a buffering effect against potential negative consequences associated with having an alcoholic parent (J. Stud. Alcohol 1997;58:272–9).

Although resilience in children of alcoholics is still not fully understood–a recent study by the University of Michigan, Ann Arbor, that has identified differences in neural activation mechanisms between vulnerable and resilient children of alcoholic parents adds a new dimension to the research in this arena (Alcohol Clin. Exp. Res. 2008;32:414–26)–the available evidence suggests that building resilience is a critical intervention goal.

For example, in a school-based prevention intervention called Students Together and Resourceful (STAR)–identified as a model program by SAMSHA–children of alcoholics gain self-efficacy through education about alcoholism and its effects on the family as well as group exercises that allow participants to recognize and express their feelings and to practice problem-solving, stress-management, and alcohol-refusal skills. In randomized trials comparing outcomes of children of alcoholics who did and did not participate in the intervention, participants attained improved self-concept as well as decreases in depression (Pediatrics 1999;103:1112–21).

Certain elements of the STAR program should be universal to all interventions for this population, according to lead author James Emshoff, Ph.D., professor of psychology at Georgia State University, Atlanta. These include “skill building in the areas of coping and social competence, social support, an outlet for the safe expression of feelings, and healthy, alternative activities.”

Perspective

Children of alcoholic parents are at risk for negative mental health outcomes. But many overcome the genetic, biologic, and, often, environmental odds that are stacked against them and become competent, mentally healthy adults. Whether innate or acquired, resiliency keeps risk factors from morphing into predictive factors.

Resilient adolescents share several well-defined characteristics. They include:

▸ Curiosity and intellectual mastery.

▸ Compassion, with detachment.

▸ The ability to conceptualize.

▸ The conviction of one's right to survive.

▸ The ability to remember and evoke images of good and sustaining figures.

▸ The ability to be in touch with affects.

▸ A goal to live for support, and the ability to attract and use it.

▸ A vision of the possibility and desirability of restored civilized moral order.

▸ The need and ability to help others.

▸ Resourcefulness.

▸ The capacity to turn traumatic helplessness into learned helpfulness.

Resiliency in at-risk youth can be cultivated. The best way is to strengthen these individuals is through family-based interventions. The most researched family-based intervention is found in the Strong African-American Families (SAAF) program, which increases protective factors that should prevent adolescents from using drugs. Interventions based on this premise also can be useful for children of alcoholics.

The SAAF intervention teaches parents how to communicate with their children in ways that nurture connectedness. The intervention guides parents on how to train their children to be responsive–but not overly reactive–to situations in their lives. The intervention also teaches children how to have a sense of power by resisting peer pressure to use drugs and alcohol.

Some children of alcoholics may be in situations that are not amenable to family-based interventions, in which case society has to provide support in the form of activities that occur out of the family context, through school- or church-based interventions, for example.

Involvement in activities such as sports teams, scouting, music programs, and martial arts training also can help children build a sense of achievement, acceptance, and self-efficacy. Positive role models with whom the children can identify also foster resiliency.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

The legacy of parental alcoholism cuts deep. Nearly 6.2 million children in the United States younger than 18 years old live with at least one parent who is currently dependent on alcohol, according to estimates from the 1996 National Household Survey on Drug Abuse (NHSDA, now known as the National Survey on Drug Use and Health). The number increases exponentially when it is broadened to include those children living with adults who have abused or been dependent on alcohol some time in their lives.

Research has long established that having an alcoholic parent increases a child's risk for multiple negative behavioral and developmental outcomes. That increased risk is conveyed through social, emotional, environmental, and biologic pathways. In particular, many studies have focused on the rates of alcohol and drug use and abuse among children of alcoholics, and most have similarly concluded that this population is significantly more vulnerable to substance abuse problems than their peers from nonalcoholic families.

Data from a national epidemiologic survey out of Johns Hopkins University, Baltimore, for example, show that children of a parent with active alcohol dependence initiated use of alcohol, cigarettes, and marijuana earlier and at higher age-specific rates than children who did not have an alcohol-dependent parent.

Using NHSDA information collected from 1995 to 1997, the investigators identified a sample of 2,888 parent-child pairs, which included 114 children of alcohol-dependent parents and 2,774 children whose interviewed parent was not dependent on alcohol. The odds ratios for past-year tobacco, alcohol, and marijuana use for the children with alcoholic parents were 3.2, 1.6, and 2.9, respectively.

The differences in substance use between the two groups started to emerge as early as age 9 years, and the additional risk was sustained at least through age 17 years, the authors wrote. By 17 years, 73% the children of alcoholic parents had smoked cigarettes, 70% had begun drinking alcohol, and 41% had smoked marijuana, compared with 44%, 57%, and 26%, respectively, of the children from nonalcoholic homes (Drug Alcohol. Depend. 2001;65:1–8).

In addition to an increased risk for substance use in this population, there also appears to be a greater likelihood of an accelerated trajectory from onset of drinking and drug use to problem substance use, a recent study by Andrea Hussong, Ph.D., of the University of North Carolina, Chapel Hill, and her colleagues shows. Using longitudinal data from a community-based sample, the investigators conducted survival analyses and determined that children of alcoholics progressed more quickly from initial adolescent alcohol use to the onset of disorder than matched controls, even after controlling for externalizing symptoms and heavier drinking patterns at initiation. A similar “telescoping” risk was observed for drug disorders (J. Abnorm. Psychol. 2008;117:63–78).

With respect to illicit drug use, adolescent children of alcoholics who use drugs are more likely to continue doing so during their transition to young adulthood than their peers from nonalcoholic families. In a study that tracked and monitored the drug use habits of 545 adolescent children of alcoholics and demographically matched children of nonalcoholic parents for 15 years, David B. Flora, Ph.D., of the University of North Carolina at Chapel Hill, and his colleagues determined that the control group significantly decreased their drug use during this time, consistent with national data, while the children of alcoholics did not.

The findings show that “[children of alcoholics] do not typically follow the normative trend by which individuals are expected to mature out of drug use before age 30,” the authors wrote (Psychol. Addict. Behav. 2005;19:352–62).

The investigators also looked at the impact of marriage on drug use trajectories in young adult children of alcoholics and determined that “marriage mediated but did not moderate the relations between parental alcoholism and the rate of change in drug use during the transition into young adulthood and the level of drug use at ages 25 to 30.”

Although marriage predicted the amount of drug use in men 25–30 years old–about 94% of married men either remained abstinent from drugs or decreased their drug use–the children of alcoholics in this study were less likely to be married and thus not only had smaller decreases in drug use between 25 and 30, they had higher levels of drug use overall, according to the authors.

In addition to a proclivity for alcohol and drug use and abuse, children of alcoholics are at increased risk for other negative outcomes, including conduct problems, aggression, depression, and anxiety, according to the Substance Abuse and Mental Health Services Administration (SAMSHA).

But not all children of alcoholics succumb to the potential negative consequences. In fact, studies suggest that, despite the odds, a large proportion of children of alcoholics do not develop serious problems.

In an often-cited longitudinal study of children of alcoholics born on the Hawaiian island of Kauai, psychologist Emmy Werner, Ph.D., of the University of California, Davis, reported on 49 children of alcoholic parents who were raised in chronic poverty from birth to 18 years. Although 41% of the study participants had developed coping problems by age 18, 59% appeared to cope well and had not developed serious problems. Among the shared characteristics of the “resilient” children were adequate communication skills, average intelligence, a desire to achieve, and the ability to get positive attention from other people (J. Stud. Alcohol. 1986;47:34–40).

A later report on the same cohort showed that study participants who effectively coped with the trauma of growing up with an alcoholic parent and became competent adults by age 32 had relied on more sources of support in their childhood than did those offspring of alcoholics with coping problems (Subst. Use Misuse 2004; 39:699–720).

In a separate 3-year study of 267 adolescents, including 127 children of alcoholics, self-awareness, a perceived control over one's environment, and the possession of cognitive coping skills were all identified as having a buffering effect against potential negative consequences associated with having an alcoholic parent (J. Stud. Alcohol 1997;58:272–9).

Although resilience in children of alcoholics is still not fully understood–a recent study by the University of Michigan, Ann Arbor, that has identified differences in neural activation mechanisms between vulnerable and resilient children of alcoholic parents adds a new dimension to the research in this arena (Alcohol Clin. Exp. Res. 2008;32:414–26)–the available evidence suggests that building resilience is a critical intervention goal.

For example, in a school-based prevention intervention called Students Together and Resourceful (STAR)–identified as a model program by SAMSHA–children of alcoholics gain self-efficacy through education about alcoholism and its effects on the family as well as group exercises that allow participants to recognize and express their feelings and to practice problem-solving, stress-management, and alcohol-refusal skills. In randomized trials comparing outcomes of children of alcoholics who did and did not participate in the intervention, participants attained improved self-concept as well as decreases in depression (Pediatrics 1999;103:1112–21).

Certain elements of the STAR program should be universal to all interventions for this population, according to lead author James Emshoff, Ph.D., professor of psychology at Georgia State University, Atlanta. These include “skill building in the areas of coping and social competence, social support, an outlet for the safe expression of feelings, and healthy, alternative activities.”

Perspective

Children of alcoholic parents are at risk for negative mental health outcomes. But many overcome the genetic, biologic, and, often, environmental odds that are stacked against them and become competent, mentally healthy adults. Whether innate or acquired, resiliency keeps risk factors from morphing into predictive factors.

Resilient adolescents share several well-defined characteristics. They include:

▸ Curiosity and intellectual mastery.

▸ Compassion, with detachment.

▸ The ability to conceptualize.

▸ The conviction of one's right to survive.

▸ The ability to remember and evoke images of good and sustaining figures.

▸ The ability to be in touch with affects.

▸ A goal to live for support, and the ability to attract and use it.

▸ A vision of the possibility and desirability of restored civilized moral order.

▸ The need and ability to help others.

▸ Resourcefulness.

▸ The capacity to turn traumatic helplessness into learned helpfulness.

Resiliency in at-risk youth can be cultivated. The best way is to strengthen these individuals is through family-based interventions. The most researched family-based intervention is found in the Strong African-American Families (SAAF) program, which increases protective factors that should prevent adolescents from using drugs. Interventions based on this premise also can be useful for children of alcoholics.

The SAAF intervention teaches parents how to communicate with their children in ways that nurture connectedness. The intervention guides parents on how to train their children to be responsive–but not overly reactive–to situations in their lives. The intervention also teaches children how to have a sense of power by resisting peer pressure to use drugs and alcohol.

Some children of alcoholics may be in situations that are not amenable to family-based interventions, in which case society has to provide support in the form of activities that occur out of the family context, through school- or church-based interventions, for example.

Involvement in activities such as sports teams, scouting, music programs, and martial arts training also can help children build a sense of achievement, acceptance, and self-efficacy. Positive role models with whom the children can identify also foster resiliency.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

“So many feelings and so much pain

Your death really hurt me; I'll never be the same

I try to express it, try to explain

So many feelings and so much pain.”

These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.

The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.

In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).

The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).

The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).

The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.

Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).

Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.

Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.

The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).

Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.

A preventive approach to adolescent grief does not, however, imply that the grief is preventable, but rather that the potential negative consequences can be minimized by providing bereaved teens the support they need to develop into mentally healthy adults. Importantly, according to Donna Schuurman, Ed.D., national director of the Dougy Center for Grieving Children and Families in Portland, Ore., “Grief is not an illness that needs to be cured. It's not a task with definable, sequential steps. It's not a bridge to cross, a burden to bear, or an experience to recover from. It is a normal, healthy, and predictable response to loss.”

In this regard, grieving children and adolescents need to be allowed to grieve and to make their own meaning in a safe, healthy environment, Dr. Schuurman said.

The above song lyrics represent what can happen when bereaved adolescents are supported in their grieving process. The lyrics are a product of an integrated grief model and music therapy protocol called the Grief Song-Writing Process (GSWP) developed and implemented by Mr. Dalton, the music therapist and mental health counselor, and Robert E. Krout, Ed.D., head of the music therapy department at Southern Methodist University, Dallas (Music Therapy Perspectives 2006;24:94-107).

The development of the GSWP comprised three phases: a descriptive, thematic analysis of songs previously written by bereaved adolescents in individual music therapy; a comparison of existing grief models with the song theme areas, and the identification of an integrated grief model, including five grief process areas (understanding, feeling, remembering, integrating, and growing); and the actual songwriting protocol through which bereaved adolescents created music and wrote original lyrics that focused on each of the five grief process areas. The 7-week GSWP protocol was implemented with four groups of bereaved adolescents ranging in age from 12 to 18 years old. Each of the seven sessions had a specific purpose. The first session was designed to develop group cohesion, clarify guidelines, and explore instruments and recording technologies. Education about grieving myths and normal grief reactions was incorporated into this session. In the second session, which focused on the grief theme of understanding, group members were encouraged to share their stories and individual experiences using the following chorus lyric from a precomposed song as a guide: “This is how it happened.”

Sessions three, four, and five, respectively, focused on the themes of feeling, remembering, and integrating, also using a precomposed lyric as a starting point. The focus of the sixth session was the theme of growing. Finally, session seven was a memorial and celebration of the lives of the loved ones who had died, according to the authors.

“Songwriting using the GSWP proved to be engaging and offered a safe, creative method of addressing the difficult subject matter of a loved one's death,” the authors wrote. The findings of a pilot study measuring progress in the five grief process areas addressed by the GSWP using a 30-item measure called the Grief Processing Scale developed and validated by the authors suggested positive changes for participants in the treatment groups relative to controls in overall scores as well as in scores from each of the five grief subscales, the authors reported.

Healthy, adaptive grief will be an ongoing challenge for bereaved adolescents. But the development of flexible interventions such as the GSWP should be promoted in order to provide adolescents with “creative ways in which to progress through their own unique journeys of healing,” the authors stressed.

Perspective

If you have models for how life works, you feel a sense of mastery and power because, as a result of knowing, you can adjust your thinking and behavior to make yourself less vulnerable. This is a critical component of building resiliency in bereaved adolescents.

Helping adolescents develop and understand models of how life and death operate, for example, aids in the development of their cognitive capacity to understand where overwhelming feelings originate and how to control them. By being able to talk about patterns in life–that predictability marks some but not all events and that fairness and justice mark some but not all outcomes, as per the Fleming/Adolph construct–an adolescent gains some frontal lobe understanding of the emotional storm that has been set off by the death.

Through that understanding, the adolescent becomes better equipped to actively respond to the emotional storm rather than passively reacting to it. Thus, instead of “feel and react,” the adolescent learns to “feel, stop, think, then act consciously.” In this way, therapy can help guide youth to engage in acts of mastery and self-control over their grief, which translates into a sense of power and self-confidence.

The simple act of feeling connected to an empathetic therapist who can name and understand the adolescent's pain and who provides a safe environment in which to ask the “Why me?” question and make the “God is not fair” accusation helps relieve the pain. It can also play an important role in mitigating the issues that can plague grieving adolescents, including self-consciousness; fear of being labeled abnormal; feelings of detachment, shame, and guilt; behavioral disturbances; alcohol and drug use; violence; and sexual acting out.

The need for such a connection is especially important as adolescents move through developmental stages and achieve different levels of understanding. Having a safe place in which to revisit the death and fit the accompanying emotions into the bigger grief puzzle gives the adolescent insight into the complete picture.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Depression in adolescent mothers is linked to an increased risk of rapid subsequent pregnancy, and these findings should come as no surprise.

In a secondary analysis of data drawn from two consecutive longitudinal risk reduction interventions, Dr. Beth Barnet and her colleagues in the department of family and community medicine at the University of Maryland, Baltimore, discovered that depressive symptoms were associated with a 44% increase in risk of subsequent pregnancy among 269 predominantly African American and low income teens.

The study included 297 pregnant adolescents aged 12–18 who received prenatal care at one of five community-based prenatal sites. At enrollment, the teens underwent a baseline structured interview and were randomly assigned to a subsequent pregnancy prevention intervention or to a usual-care control. Research staff administered structured follow-up questionnaires at 1 and 2 years post partum.

Of the 269 teens who completed at least one of the follow-up questionnaires, 46% had depressive symptoms at baseline, the authors reported in the March issue of the Archives of Pediatric and Adolescent Medicine. Of the 245 teens who completed 2 years of follow-up, 120 experienced a subsequent pregnancy within 2 years of childbirth. Of the 24 who were followed for only 1 year, 9 had a subsequent pregnancy during that time, they wrote (Arch. Pediatr. Adolesc. Med. 2008;162:246–52).

“The hazard ratio of subsequent pregnancy was significantly greater among the 112 teens with baseline depressive symptoms,” the authors wrote, noting that the increased risk remained significant even after adjustment for possible confounders, including age, education, Medicaid status, exposure to violence, substance use, and relationship with the baby's father.

This study is the first to demonstrate with longitudinal data that depressive symptoms precede subsequent pregnancy in adolescent mothers and might be a determinant of this. However, in context of the following data on depression and adolescent mothers, the results could have been predicted:

▸ Depression is a well-known nonsexual antecedent of teen pregnancy. In a recent national study using longitudinal data from more than 4,000 middle school and high school students, depressive symptoms in boys and girls were predictive of subsequent sexual risk behavior, including condom nonuse at last sex, birth control nonuse at last sex, and multiple sexual partners (Pediatrics July 2006;118:189–200).

▸ Depression is common among adolescents. According to the 2001 Youth Risk Behavior Survey of more than 13,000 students, 28% of U.S. high school students reported severe depressive feelings (MMWR 2002;51[SS04]:1–64). In a 2005 report of the results from the Office of Applied Studies' National Survey on Drug Use and Health, the lifetime prevalence of depression among adolescents was estimated to be 14% (http://www.oas.samhsa.gov/p0000016.htm#2k4

▸ Rates of postpartum depression in adolescent mothers are significantly higher than those seen in adult mothers. According to the results of a recent integrative review of the literature on postpartum depression in adolescent mothers by pediatric nurse practitioner Vanessa Reid of New London, Conn., the prevalence of postpartum depression among women of all ages is estimated to be between 20% and 28% during the immediate postpartum period, compared with rates between 53% and 56% among adolescents (J. Pediatr. Health Care 2007;21:289–98).

▸ Rates of postpartum depression among African American adolescents are nearly twice as high as those observed in white adolescents, according to the result of a 1998 report on the National Maternal and Infant Health Survey (Am. J. Public Health 1998;88:266–70).

Without a doubt, the odds are clearly stacked against adolescent mothers and, by default, their offspring. Multiple studies examining the impact of maternal depressive symptoms on offspring have shown that depression can interfere with a mother's ability to provide emotional and psychological support and attachment, as well as proper and adequate nutrition and physical care, for her infant, according to Ms. Reid.

“The results of studies that examined the relationship between maternal depressive symptoms and child outcomes revealed negative feeding interactions, negative or less positive interaction behaviors, child problem behaviors in preschool, and general pediatric complications, including lower weight, shorter length, and smaller head circumference,” Ms. Reid said.

In addition, “repeat adolescent pregnancy and birth are associated with poorer pregnancy outcomes, less educational attainment, lower future income, and greater dependence on public assistance,” wrote Dr. Barnet and her colleagues. “Children born into families with short interpregnancy intervals are exposed to increased parenting stress and negative parenting behaviors.”

Numerous interventions have attempted to reduce rapid subsequent pregnancy in adolescents, but “none that I am aware of have specifically targeted depression,” Dr. Barnet said. Instead, many such efforts have focused on such factors as access to contraceptives, education, and social support. The outcomes have been disappointing, she said.

For example, the subsequent pregnancy risk reduction interventions from which Dr. Barnet and her colleagues drew data for their secondary analysis comprised weekly or monthly home visits beginning during the index pregnancy and continuing for two years. The interventions were facilitated by trained paraprofessionals who provided parenting instruction, case management, and motivational interviewing. Neither of the consecutive interventions achieved their primary intervention goal, nor were maternal depressive symptoms affected, she said.

In contrast, research has shown that treating depression in mothers can improve mother and child outcomes. Findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that remission of maternal depression has a significant positive effect on the health and well-being of both mothers and children (JAMA 2006;295:1389–98).

Although it is not known whether treating depression in adolescent mothers will decrease the risk of rapid subsequent pregnancies, “our findings suggest that depression may be an important malleable risk factor,” Dr. Barnet said. As such, she noted, depression in this group needs to be identified and treated, and doing so requires the implementation of a model of health care in which multidisciplinary primary care teams provide care coordination across clinic and community settings.

Schools might be an important front-line resource in this regard. For example, although it was not developed to prevent subsequent teen pregnancies or to address maternal depression, the Cradle to Classroom program, piloted successfully in the Chicago Public Schools, might affect both. The comprehensive program, designed to develop parenting skills in adolescent parents, help them finish high school, and promote healthy outcomes for the teens and their offspring, includes extensive in-school academic, social, and health supports for young mothers and an intensive home visiting program for the adolescent parents and their babies.

Of the 2,000 or so teens from 54 Chicago schools who had babies in 2002 and who participated in the program, only five had a repeat pregnancy while still in school. Also, all 495 seniors in the program graduated, and more than 75% went on to 2- or 4-year colleges (JAMA 2003;290:586).

Improving outcomes for teen mothers and their children requires this type of comprehensive strategy, according to Dr. Barnet. She and her colleagues stress the need for protocols that incorporate systematic practice changes and collaborative care teams.

Perspective

Risk factors are not predictive factors because of the presence of protective factors. This truism should be the mantra of preventive mental health.

Depression in adolescent girls has been linked to an increase in high-risk sex behavior and, consequently, pregnancy. Yet, not all girls with depression engage in high-risk sex and become pregnant.

Much attention has been focused on determining whether depression leads to an increased risk of high-risk sex and pregnancy among adolescents or whether it is a consequence of such outcomes. But the more practical research question in terms of designing an effective teen pregnancy-prevention intervention should be this: “What protective factors are keeping the nonpregnant adolescent girls who are depressed from getting pregnant?”

The answer, I suspect, will be the same protective factors that foster resilience in some trauma-exposed teens, and the same ones that keep some low-income, underprivileged nonwhite teens out of trouble: a strong social fabric, self-esteem, self-efficacy, a sense of belonging, and access to community resources.

Interventions designed to optimize these factors will likely have the most benefit across outcomes. The Cradle to Classroom initiative is a perfect example. Developed as a tool to keep pregnant teens in school through high school graduation, the program not only is associated with reduced dropout rates among participants. It also has been linked to increased personal growth and development in terms of college enrollment, improved parent/child interactions, and the prevention of rapid subsequent pregnancies. It succeeds by fortifying the protective factors necessary to keeping these kids on track.

In contrast, interventions designed to educate depressed teen mothers about how not to be depressed or how not to get pregnant again don't work. The fact that there are still academics who believe that education alone can change behavior is laughable. Of course, it is easier to throw education at a problem than it is to design a comprehensive and thorough intervention. But easier isn't better; in most cases, it's not nearly enough.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Depression in adolescent mothers is linked to an increased risk of rapid subsequent pregnancy, and these findings should come as no surprise.

In a secondary analysis of data drawn from two consecutive longitudinal risk reduction interventions, Dr. Beth Barnet and her colleagues in the department of family and community medicine at the University of Maryland, Baltimore, discovered that depressive symptoms were associated with a 44% increase in risk of subsequent pregnancy among 269 predominantly African American and low income teens.

The study included 297 pregnant adolescents aged 12–18 who received prenatal care at one of five community-based prenatal sites. At enrollment, the teens underwent a baseline structured interview and were randomly assigned to a subsequent pregnancy prevention intervention or to a usual-care control. Research staff administered structured follow-up questionnaires at 1 and 2 years post partum.

Of the 269 teens who completed at least one of the follow-up questionnaires, 46% had depressive symptoms at baseline, the authors reported in the March issue of the Archives of Pediatric and Adolescent Medicine. Of the 245 teens who completed 2 years of follow-up, 120 experienced a subsequent pregnancy within 2 years of childbirth. Of the 24 who were followed for only 1 year, 9 had a subsequent pregnancy during that time, they wrote (Arch. Pediatr. Adolesc. Med. 2008;162:246–52).

“The hazard ratio of subsequent pregnancy was significantly greater among the 112 teens with baseline depressive symptoms,” the authors wrote, noting that the increased risk remained significant even after adjustment for possible confounders, including age, education, Medicaid status, exposure to violence, substance use, and relationship with the baby's father.

This study is the first to demonstrate with longitudinal data that depressive symptoms precede subsequent pregnancy in adolescent mothers and might be a determinant of this. However, in context of the following data on depression and adolescent mothers, the results could have been predicted:

▸ Depression is a well-known nonsexual antecedent of teen pregnancy. In a recent national study using longitudinal data from more than 4,000 middle school and high school students, depressive symptoms in boys and girls were predictive of subsequent sexual risk behavior, including condom nonuse at last sex, birth control nonuse at last sex, and multiple sexual partners (Pediatrics July 2006;118:189–200).

▸ Depression is common among adolescents. According to the 2001 Youth Risk Behavior Survey of more than 13,000 students, 28% of U.S. high school students reported severe depressive feelings (MMWR 2002;51[SS04]:1–64). In a 2005 report of the results from the Office of Applied Studies' National Survey on Drug Use and Health, the lifetime prevalence of depression among adolescents was estimated to be 14% (http://www.oas.samhsa.gov/p0000016.htm#2k4

▸ Rates of postpartum depression in adolescent mothers are significantly higher than those seen in adult mothers. According to the results of a recent integrative review of the literature on postpartum depression in adolescent mothers by pediatric nurse practitioner Vanessa Reid of New London, Conn., the prevalence of postpartum depression among women of all ages is estimated to be between 20% and 28% during the immediate postpartum period, compared with rates between 53% and 56% among adolescents (J. Pediatr. Health Care 2007;21:289–98).

▸ Rates of postpartum depression among African American adolescents are nearly twice as high as those observed in white adolescents, according to the result of a 1998 report on the National Maternal and Infant Health Survey (Am. J. Public Health 1998;88:266–70).

Without a doubt, the odds are clearly stacked against adolescent mothers and, by default, their offspring. Multiple studies examining the impact of maternal depressive symptoms on offspring have shown that depression can interfere with a mother's ability to provide emotional and psychological support and attachment, as well as proper and adequate nutrition and physical care, for her infant, according to Ms. Reid.

“The results of studies that examined the relationship between maternal depressive symptoms and child outcomes revealed negative feeding interactions, negative or less positive interaction behaviors, child problem behaviors in preschool, and general pediatric complications, including lower weight, shorter length, and smaller head circumference,” Ms. Reid said.

In addition, “repeat adolescent pregnancy and birth are associated with poorer pregnancy outcomes, less educational attainment, lower future income, and greater dependence on public assistance,” wrote Dr. Barnet and her colleagues. “Children born into families with short interpregnancy intervals are exposed to increased parenting stress and negative parenting behaviors.”

Numerous interventions have attempted to reduce rapid subsequent pregnancy in adolescents, but “none that I am aware of have specifically targeted depression,” Dr. Barnet said. Instead, many such efforts have focused on such factors as access to contraceptives, education, and social support. The outcomes have been disappointing, she said.

For example, the subsequent pregnancy risk reduction interventions from which Dr. Barnet and her colleagues drew data for their secondary analysis comprised weekly or monthly home visits beginning during the index pregnancy and continuing for two years. The interventions were facilitated by trained paraprofessionals who provided parenting instruction, case management, and motivational interviewing. Neither of the consecutive interventions achieved their primary intervention goal, nor were maternal depressive symptoms affected, she said.

In contrast, research has shown that treating depression in mothers can improve mother and child outcomes. Findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that remission of maternal depression has a significant positive effect on the health and well-being of both mothers and children (JAMA 2006;295:1389–98).

Although it is not known whether treating depression in adolescent mothers will decrease the risk of rapid subsequent pregnancies, “our findings suggest that depression may be an important malleable risk factor,” Dr. Barnet said. As such, she noted, depression in this group needs to be identified and treated, and doing so requires the implementation of a model of health care in which multidisciplinary primary care teams provide care coordination across clinic and community settings.

Schools might be an important front-line resource in this regard. For example, although it was not developed to prevent subsequent teen pregnancies or to address maternal depression, the Cradle to Classroom program, piloted successfully in the Chicago Public Schools, might affect both. The comprehensive program, designed to develop parenting skills in adolescent parents, help them finish high school, and promote healthy outcomes for the teens and their offspring, includes extensive in-school academic, social, and health supports for young mothers and an intensive home visiting program for the adolescent parents and their babies.

Of the 2,000 or so teens from 54 Chicago schools who had babies in 2002 and who participated in the program, only five had a repeat pregnancy while still in school. Also, all 495 seniors in the program graduated, and more than 75% went on to 2- or 4-year colleges (JAMA 2003;290:586).

Improving outcomes for teen mothers and their children requires this type of comprehensive strategy, according to Dr. Barnet. She and her colleagues stress the need for protocols that incorporate systematic practice changes and collaborative care teams.

Perspective

Risk factors are not predictive factors because of the presence of protective factors. This truism should be the mantra of preventive mental health.

Depression in adolescent girls has been linked to an increase in high-risk sex behavior and, consequently, pregnancy. Yet, not all girls with depression engage in high-risk sex and become pregnant.

Much attention has been focused on determining whether depression leads to an increased risk of high-risk sex and pregnancy among adolescents or whether it is a consequence of such outcomes. But the more practical research question in terms of designing an effective teen pregnancy-prevention intervention should be this: “What protective factors are keeping the nonpregnant adolescent girls who are depressed from getting pregnant?”

The answer, I suspect, will be the same protective factors that foster resilience in some trauma-exposed teens, and the same ones that keep some low-income, underprivileged nonwhite teens out of trouble: a strong social fabric, self-esteem, self-efficacy, a sense of belonging, and access to community resources.

Interventions designed to optimize these factors will likely have the most benefit across outcomes. The Cradle to Classroom initiative is a perfect example. Developed as a tool to keep pregnant teens in school through high school graduation, the program not only is associated with reduced dropout rates among participants. It also has been linked to increased personal growth and development in terms of college enrollment, improved parent/child interactions, and the prevention of rapid subsequent pregnancies. It succeeds by fortifying the protective factors necessary to keeping these kids on track.

In contrast, interventions designed to educate depressed teen mothers about how not to be depressed or how not to get pregnant again don't work. The fact that there are still academics who believe that education alone can change behavior is laughable. Of course, it is easier to throw education at a problem than it is to design a comprehensive and thorough intervention. But easier isn't better; in most cases, it's not nearly enough.

By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at cpnews@elsevier.com

Depression in adolescent mothers is linked to an increased risk of rapid subsequent pregnancy, and these findings should come as no surprise.

In a secondary analysis of data drawn from two consecutive longitudinal risk reduction interventions, Dr. Beth Barnet and her colleagues in the department of family and community medicine at the University of Maryland, Baltimore, discovered that depressive symptoms were associated with a 44% increase in risk of subsequent pregnancy among 269 predominantly African American and low income teens.

The study included 297 pregnant adolescents aged 12–18 who received prenatal care at one of five community-based prenatal sites. At enrollment, the teens underwent a baseline structured interview and were randomly assigned to a subsequent pregnancy prevention intervention or to a usual-care control. Research staff administered structured follow-up questionnaires at 1 and 2 years post partum.

Of the 269 teens who completed at least one of the follow-up questionnaires, 46% had depressive symptoms at baseline, the authors reported in the March issue of the Archives of Pediatric and Adolescent Medicine. Of the 245 teens who completed 2 years of follow-up, 120 experienced a subsequent pregnancy within 2 years of childbirth. Of the 24 who were followed for only 1 year, 9 had a subsequent pregnancy during that time, they wrote (Arch. Pediatr. Adolesc. Med. 2008;162:246–52).

“The hazard ratio of subsequent pregnancy was significantly greater among the 112 teens with baseline depressive symptoms,” the authors wrote, noting that the increased risk remained significant even after adjustment for possible confounders, including age, education, Medicaid status, exposure to violence, substance use, and relationship with the baby's father.

This study is the first to demonstrate with longitudinal data that depressive symptoms precede subsequent pregnancy in adolescent mothers and might be a determinant of this. However, in context of the following data on depression and adolescent mothers, the results could have been predicted:

▸ Depression is a well-known nonsexual antecedent of teen pregnancy. In a recent national study using longitudinal data from more than 4,000 middle school and high school students, depressive symptoms in boys and girls were predictive of subsequent sexual risk behavior, including condom nonuse at last sex, birth control nonuse at last sex, and multiple sexual partners (Pediatrics July 2006;118:189–200).

▸ Depression is common among adolescents. According to the 2001 Youth Risk Behavior Survey of more than 13,000 students, 28% of U.S. high school students reported severe depressive feelings (MMWR 2002;51[SS04]:1–64). In a 2005 report of the results from the Office of Applied Studies' National Survey on Drug Use and Health, the lifetime prevalence of depression among adolescents was estimated to be 14% (http://www.oas.samhsa.gov/p0000016.htm#2k4

▸ Rates of postpartum depression in adolescent mothers are significantly higher than those seen in adult mothers. According to the results of a recent integrative review of the literature on postpartum depression in adolescent mothers by pediatric nurse practitioner Vanessa Reid of New London, Conn., the prevalence of postpartum depression among women of all ages is estimated to be between 20% and 28% during the immediate postpartum period, compared with rates between 53% and 56% among adolescents (J. Pediatr. Health Care 2007;21:289–98).

▸ Rates of postpartum depression among African American adolescents are nearly twice as high as those observed in white adolescents, according to the result of a 1998 report on the National Maternal and Infant Health Survey (Am. J. Public Health 1998;88:266–70).

Without a doubt, the odds are clearly stacked against adolescent mothers and, by default, their offspring. Multiple studies examining the impact of maternal depressive symptoms on offspring have shown that depression can interfere with a mother's ability to provide emotional and psychological support and attachment, as well as proper and adequate nutrition and physical care, for her infant, according to Ms. Reid.

“The results of studies that examined the relationship between maternal depressive symptoms and child outcomes revealed negative feeding interactions, negative or less positive interaction behaviors, child problem behaviors in preschool, and general pediatric complications, including lower weight, shorter length, and smaller head circumference,” Ms. Reid said.

In addition, “repeat adolescent pregnancy and birth are associated with poorer pregnancy outcomes, less educational attainment, lower future income, and greater dependence on public assistance,” wrote Dr. Barnet and her colleagues. “Children born into families with short interpregnancy intervals are exposed to increased parenting stress and negative parenting behaviors.”

Numerous interventions have attempted to reduce rapid subsequent pregnancy in adolescents, but “none that I am aware of have specifically targeted depression,” Dr. Barnet said. Instead, many such efforts have focused on such factors as access to contraceptives, education, and social support. The outcomes have been disappointing, she said.

For example, the subsequent pregnancy risk reduction interventions from which Dr. Barnet and her colleagues drew data for their secondary analysis comprised weekly or monthly home visits beginning during the index pregnancy and continuing for two years. The interventions were facilitated by trained paraprofessionals who provided parenting instruction, case management, and motivational interviewing. Neither of the consecutive interventions achieved their primary intervention goal, nor were maternal depressive symptoms affected, she said.

In contrast, research has shown that treating depression in mothers can improve mother and child outcomes. Findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that remission of maternal depression has a significant positive effect on the health and well-being of both mothers and children (JAMA 2006;295:1389–98).

Although it is not known whether treating depression in adolescent mothers will decrease the risk of rapid subsequent pregnancies, “our findings suggest that depression may be an important malleable risk factor,” Dr. Barnet said. As such, she noted, depression in this group needs to be identified and treated, and doing so requires the implementation of a model of health care in which multidisciplinary primary care teams provide care coordination across clinic and community settings.

Schools might be an important front-line resource in this regard. For example, although it was not developed to prevent subsequent teen pregnancies or to address maternal depression, the Cradle to Classroom program, piloted successfully in the Chicago Public Schools, might affect both. The comprehensive program, designed to develop parenting skills in adolescent parents, help them finish high school, and promote healthy outcomes for the teens and their offspring, includes extensive in-school academic, social, and health supports for young mothers and an intensive home visiting program for the adolescent parents and their babies.

Of the 2,000 or so teens from 54 Chicago schools who had babies in 2002 and who participated in the program, only five had a repeat pregnancy while still in school. Also, all 495 seniors in the program graduated, and more than 75% went on to 2- or 4-year colleges (JAMA 2003;290:586).

Improving outcomes for teen mothers and their children requires this type of comprehensive strategy, according to Dr. Barnet. She and her colleagues stress the need for protocols that incorporate systematic practice changes and collaborative care teams.

Perspective

Risk factors are not predictive factors because of the presence of protective factors. This truism should be the mantra of preventive mental health.

Depression in adolescent girls has been linked to an increase in high-risk sex behavior and, consequently, pregnancy. Yet, not all girls with depression engage in high-risk sex and become pregnant.

Much attention has been focused on determining whether depression leads to an increased risk of high-risk sex and pregnancy among adolescents or whether it is a consequence of such outcomes. But the more practical research question in terms of designing an effective teen pregnancy-prevention intervention should be this: “What protective factors are keeping the nonpregnant adolescent girls who are depressed from getting pregnant?”

The answer, I suspect, will be the same protective factors that foster resilience in some trauma-exposed teens, and the same ones that keep some low-income, underprivileged nonwhite teens out of trouble: a strong social fabric, self-esteem, self-efficacy, a sense of belonging, and access to community resources.

Interventions designed to optimize these factors will likely have the most benefit across outcomes. The Cradle to Classroom initiative is a perfect example. Developed as a tool to keep pregnant teens in school through high school graduation, the program not only is associated with reduced dropout rates among participants. It also has been linked to increased personal growth and development in terms of college enrollment, improved parent/child interactions, and the prevention of rapid subsequent pregnancies. It succeeds by fortifying the protective factors necessary to keeping these kids on track.

In contrast, interventions designed to educate depressed teen mothers about how not to be depressed or how not to get pregnant again don't work. The fact that there are still academics who believe that education alone can change behavior is laughable. Of course, it is easier to throw education at a problem than it is to design a comprehensive and thorough intervention. But easier isn't better; in most cases, it's not nearly enough.