The Mental Health Social Worker

A new NIMH-funded grant aims to increase suicide detection and prevention efforts among patients who present with suicide risk factors in hospital emergency departments.

The Emergency Department Safety Assessment and Follow-up Evaluation (EDSAFE) trial will be coordinated by the Emergency Medicine Network (EMNet), which is based at Massachusetts General Hospital. The team of researchers will be led by Edwin D. Boudreaux, Ph.D., of the University of Massachusetts, Carlos A. Camargo, Jr., M.D., DrPH, of Massachusetts General Hospital and Harvard Medical School, and Ivan Miller, Ph.D., of Butler Hospital in Providence, RI. The project is expected to enroll nearly 1,420 participants over five years.

EDSAFE will be conducted in three phases. The first phase will assess treatment as usual (TAU) for patients. TAU typically consists of evaluating suicidal risk only among those emergency department patients who have psychiatric risk factors such as depression, suicidal thinking or behavior (ideation), or substance abuse. Often these patients are put under observation while at the hospital and are evaluated by a mental health provider. They also may be referred to a mental health professional outside the hospital, but few receive adequate follow-up care after they are discharged. During the second phase, a universal screening process will be tested in which all patients, regardless of whether they exhibit typical risk factors for suicide, will be screened for suicidal ideation. The researchers will compare universal screening with TAU to determine how well each detects suicidal patients.

During the third phase, a more intensive intervention that includes screening, brief counseling, an evaluation by a mental health provider, referral to outpatient care and other components will be implemented. Patients will then receive follow-up phone counseling. The intensive intervention will be compared to TAU and to universal screening.

The study will be conducted at eight sites throughout the nation and is set to begin in June 2010.

More Receive Psychotherapy than Medication; Study Provides New Detail on Disparities

Overall, only about half of Americans diagnosed with major depression in a given year receive treatment for it, and even fewer—about one fifth—receive treatment consistent with current practice guidelines, according to data from nationally representative surveys supported by NIMH. Among the ethnic/racial groups surveyed, African Americans and Mexican Americans had the lowest rates of use of depression care; all groups reported higher use of past-year psychotherapy vs. medication for depression.

Background

Depression is a leading cause of disability in the United States. Past research has found that many people with depression never received treatment, and that the percentage of those receiving treatment varies with ethnicity and race. In order to provide comprehensive and up-to-date information on depression care, with a particular emphasis on minority groups, NIMH’s Collaborative Psychiatric Epidemiology Surveys initiative (CPES) has combined data from three nationally representative studies: the National Survey of American Life, the National Comorbidity Survey-Replication, and the National Latino and Asian American Study.

This Study

Scientists at Wayne State University, Detroit, MI; the University of Michigan, Ann Arbor; the University of California, Los Angeles; and the Harvard School of Public Health, Boston, MA, carried out the current study, which reports on data from CPES collected between February 2001 and November 2003 from 15,762 residents 18 years and older. The size of the sample makes it possible to examine health care use in ethnic/racial groups with a new level of detail, distinguishing between groups often surveyed as one population. The investigators were able to break out types of care used, and to assess to what extent the care used was consistent with the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Finally, they examined how factors enabling healthcare access—insurance, education, and household income—influenced rates of care.

A central finding was that overall, 51 percent of all those in the study who met criteria for major depression during the prior year received some kind of treatment for it, with only 21 percent receiving care that was consistent with the APA Guidelines.

Other key study findings addressed disparities, types and quality of care received, and factors that enable access to healthcare.

• Prevalence and severity of major depression was similar among the five studied ethnic/racial groups—Mexican Americans, Puerto Ricans, Caribbean Blacks, African Americans, and non-Latino Whites. However, African Americans and Mexican Americans were least likely to receive any care or care consistent with practice guidelines. Compared with non-Latino Whites for example, of whom 54 percent with depression received care, 40 percent of African Americans and 34 percent of Mexican Americans did. The rate of care for Puerto Ricans was close to that of Whites, 50 percent.
• Across these population groups, psychotherapy was used more frequently than medications (pharmacotherapy). Overall, 34 percent received pharmacotherapy; 45 percent psychotherapy. Psychotherapy was more likely to be consistent with APA guidelines than pharmacotherapy, suggesting that adherence—the extent to which patients completed the recommended therapy—was greater for psychotherapy than pharmacotherapy. The contrast between the rates of Guideline-consistent psychotherapy and pharmacotherapy use was greatest among Caribbean Blacks, African Americans, and Mexican Americans.
• Puerto Ricans had rates of treatment use, and treatment that was consistent with care guidelines, that were similar to, or higher than, non-Latino Whites.
• Differences in factors enabling healthcare access appeared to contribute substantially to disparities in mental healthcare use, particularly for Mexican Americans. When differences in these enabling factors were controlled for statistically—so in effect, the population groups being compared had the same rates of enabling factors—the degree of disparities in use of care by Mexican Americans was reduced. For Caribbean Blacks and African Americans, statistical control of enabling factors reduced disparities in psychotherapy use, but not use of pharmacotherapy.
• Health insurance coverage was associated with a greater likelihood of depression care, but not guideline consistent care. The pattern with education was reversed: education was associated with a greater likelihood of care that was consistent with the APA Guidelines, but not with greater use of care in general.

Significance

This study, with its large sample size and emphasis on minority groups, provides a more nuanced and detailed picture of the care received for major depression among different ethnic/racial groups and of factors that contribute to disparities. Lead author Hector González at Wayne State University said that Mexican-Americans make up over two-thirds of Latinos in the U.S.: “We found in our study that there are some really distinctive differences in mental healthcare use between Mexican Americans and other Latino subgroups that have not been previously reported.” Estimates suggest that Latinos will make up close to one-third of the U.S. population by mid-century; the study findings suggest that Mexican Americans should be a focus of efforts to reduce health disparities to ensure the nation’s health in coming decades.

All groups were more likely to have received psychotherapy than pharmacotherapy. Caribbean Blacks and African Americans were particularly unlikely to receive pharmacotherapy consistent with APA guidelines; enabling factors such as education, health insurance, and income did not explain the lower rates of medication use. The authors note possible reasons for this, including research indicating that perceived discrimination can shape health care seeking. They speculate that the non-immigrant status of Puerto Ricans—and with that, greater predominance of English language use within this group—may be factors in their relatively high rates of health care use.

Findings from this study will inform future research on adherence to various depression therapies, and the factors that shape differences in care among racial/ethnic groups. “Future studies,” say the authors, “should explore the extent to which patients’ subjective experiences of racial bias may affect their access and utilization of mental healthcare.”

Reference

González, H.M., Vega, W.A., Williams, D.R., Tarraf, W., West, B.T., and Neighbors, H.W. Archives of General Psychiatry 2010;67(1):37-4

Gender Gaps Linked to Status of Women, According to New Analysis

WASHINGTON – Girls around the world are not worse at math than boys, even though boys are more confident in their math abilities, and girls from countries where gender equity is more prevalent are more likely to perform better on mathematics assessment tests, according to a new analysis of international research.

“Stereotypes about female inferiority in mathematics are a distinct contrast to the actual scientific data,” said Nicole Else-Quest, PhD, a psychology professor at Villanova University, and lead author of the meta-analysis. “These results show that girls will perform at the same level as the boys when they are given the right educational tools and have visible female role models excelling in mathematics.”

The results are reported in the latest issue of Psychological Bulletin, published by the American Psychological Association. The finding that girls around the world appear to have less confidence in their mathematical abilities could help explain why young girls are less likely than boys to pursue careers in science, technology, engineering and mathematics.

Else-Quest and her fellow researchers examined data from the Trends in International Mathematics and Science Study and the Programme for International Student Assessment, representing 493,495 students ages 14-16 from 69 countries. Both studies’ results were released in 2003, and not all countries participated in both assessments. The TIMSS focuses on basic math knowledge, while the PISA test assesses students’ ability to use their math skills in the real world. The researchers felt these two tests offered a good sampling of students’ math abilities.

While these measures tested different math abilities, there were only small gender differences for each, on average. However, from nation to nation, the size of the gender differences varied a great deal.

The two studies also assessed students’ level of confidence in their math abilities and how important they felt it was to do well in math in order to have a successful career. Despite overall similarities in math skills, boys felt significantly more confident in their abilities than girls did and were more motivated to do well.

The researchers also looked at different measures of women’s education, political involvement, welfare and income in each country. There was some variability among countries when it came to gender differences in math and how it related to the status and welfare of women. For example, if certain countries had more women in research-related positions, the girls in that country were more likely to do better in math and feel more confident of those skills.

‘This meta-analysis shows us that while the quality of instruction and curriculum affects children’s learning, so do the value that schools, teachers and families place on girls’ learning math. Girls are likely to perform as well as boys when they are encouraged to succeed,” said Else-Quest.

Article: “Cross-National Patterns of Gender Differences in Mathematics: A Meta-Analysis,” Nicole M. Else-Quest, PhD, Villanova University; Janet Shibley Hyde, PhD, University of Wisconsin-Madison; Marcia C. Linn, PhD, University of California, Berkeley. Psychological Bulletin, Vol. 136, No. 1.

Contact Dr. Nicole Else-Quest by e-mail or at (610) 519-4758.

Translational Experiments in Rats, Humans Suggest New Medication Target

A study has linked panic disorder to a wayward hormone in a brain circuit that regulates vigilance. While too little of the hormone, called orexin, is known to underlie narcolepsy, the new study suggests that too much of it may lead to panic attacks that afflict 6 million American adults.

“Targeting the brain’s orexin system may hold promise for a new generation of anti-anxiety treatments,” said Thomas R. Insel, M.D., Director of the National Institute of Mental Health (NIMH), part of the National Institutes of Health. “This is a good example of how translational experiments in rats and humans can potentially yield clinical benefits.”

NIMH grantee Anantha Shekhar, M.B., Ph.D., and colleagues at Indiana University and Lund University, report on their findings online Dec. 27, 2009 in the journal Nature Medicine. They showed that blocking orexin gene expression or its receptor prevented panic attack-like responses in rats. The study also revealed that panic disorder patients have excess levels of the hormone.

Background

Orexin, also called hypocretin, is secreted exclusively in a circuit emanating from the brain’s hypothalamus, known to regulate arousal, wakefulness and reward.

Panic attacks can be experimentally-induced by infusing susceptible humans with a normally innocuous salt called sodium lactate. The salt similarly triggers panic-like anxiety behaviors in susceptible rat strains, suggesting that something is altered in their arousal circuit. Since sodium lactate activated orexin-secreting neurons in panic-prone rats but not in control rats, the researchers hypothesized that something might be orexin.

Results of This Study

The investigators first discovered that increased gene expression in orexin-secreting neurons correlated with increases in anxiety-like behavior in panic-prone rats following sodium lactate infusions. Using a technique called RNA interference, they then protected the panic-prone rats from developing anxiety behaviors following the infusions by first injecting them with a genetically-engineered agent that prevented orexin genes from turning on. Blocking orexin receptors with a drug that specifically binds to it also blocked the anxiety like behavior following the infusions. This mirrored effects, seen in both rats and humans, of benzodiazepine medications used to treat panic disorder.

The excess sleepiness of narcolepsy, traced a decade ago to loss of orexin-secreting neurons in the arousal circuit, might seem to be an opposite state of a panic attack. However, the researchers demonstrated in rats that such sedation could not account for orexin’s effects on anxiety. Also in rats, they traced orexin neurons to their end target to pinpoint the specific brain site that accounts for the anxiety effects, disentangled from cardio-respiratory components of the panic response.

Finally, by measuring orexin in cerebrospinal fluid of 53 patients, the researchers showed that those with just panic disorder had higher levels of orexin than those with both panic disorder and depression.

Significance

Taken together, these results and other evidence suggest a critical role for an overactive orexin system in producing panic attacks, say the researchers.

What’s Next?

Medications that block the orexin receptor may provide a new therapeutic approach for the treatment of panic disorder, they add.

The research was also supported, in part, by NIH’s National Center for Research Resources.

Reference

A key role for orexin in panic anxiety. Johnson PL, Truitt W, Fitz SD, Kelley PE, Dietrich A, Sanghani S, Traskman-Bendz L, Goddard AW, Brundin, L, Shekhar A. Nature Medicine. Epub 2009 Dec 27.