Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State,Multi-Site Primary Care Practice

BackgroundAnxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care.MethodsParticipants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database.ResultsAmong participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p < .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations.DiscussionShort-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.     

Parieto-premotor functional connectivity changes during parietal lobe seizures are associated with motor semiology

ObjectivesParietal lobe seizures (PLS) are characterized by multiple clinical manifestations including motor signs. The mechanisms underlying the occurrence of motor signs are poorly understood. The main objective of this work was to estimate the functional coupling of brain regions associated with this clinical presentation.MethodsWe retrospectively selected patients affected by drug-resistant epilepsy who underwent Stereoelectroencephalography (SEEG) for pre-surgical evaluation and in whom the seizure onset zone (SOZ) was located in the parietal cortex. The SOZ was defined visually and quantitatively by the epileptogenicity index (EI) method. Two groups of seizures were defined according to the presence (“motor seizures”) or the absence (“non-motor seizures”) of motor signs. Functional connectivity (FC) estimation was based on pairwise nonlinear regression analysis (h² coefficient). To study FC changes between parietal, frontal and temporal regions, for each patient, z-score values of 16 cortico-cortical interactions were obtained comparing h² coefficients of pre-ictal, seizure onset and seizure propagation periods.ResultsWe included 22 patients, 13 with “motor seizures” and 9 with “non-motor seizures”. Resective surgery was performed in 14 patients, 8 patients had a positive surgical outcome (Engel’s class I and II). During seizure onset period, a decrease of FC was observed and was significantly more important (in comparison with background period) in “motor” seizures. This was particularly observed between parietal operculum/post-central gyrus (OP/PoCg) and mesial temporal areas. During seizure propagation, a FC increase was significantly more important (in comparison with seizure onset) in “motor seizures”, in particular between lateral pre-motor (pmL) area and precuneus, pmL and superior parietal lobule (SPL) and between inferior parietal lobule (IPL) and supplementary motor area (SMA).ConclusionsOur study shows that motor semiology in PLS is accompanied by an increase of FC between parietal and premotor cortices, significantly different than what is observed in PLS without motor semiology.SignificanceOur results indicate that preferential routes of coupling between parietal and premotor cortices are responsible for the prominent motor presentation during PLS.     

Associations of carotid artery flow parameters with MRI markers of cerebral small vessel disease and patterns of brain atrophy

ObjectivesA growing body of evidence links age related brain pathologies to systemic vascular processes. We aimed to study the prevalence and interrelations between magnetic resonance imaging (MRI) markers of cerebral small vessel disease and patterns of brain atrophy, and their association to carotid duplex ultrasound flow parameters.Materials and methodsWe investigated a population based randomised cohort of older adults (n=391) aged 70-87, part of the Swedish Good Aging in Skåne Study. Peak systolic and end diastolic velocities of the carotid arteries were measured by ultrasound, and resistivity- and pulsatility indexes were calculated. Subjects with increased peak systolic velocity indicating carotid stenosis were excluded from analysis. Nine MRI findings were rated by visual scales: white matter changes, pontine white matter changes, microbleeds, lacunar infarctions, medial temporal lobe atrophy, global cortical atrophy, parietal atrophy, precuneus atrophy and central atrophy.ResultsMRI pathologies were found in 80% of subjects. Mean end diastolic velocity in common carotid arteries was inversely associated with white matter hyperintensities (OR=0.92; p=0.004), parietal lobe atrophy (OR=0.94; p=0.039), global cortical atrophy (OR=0.90; p=0.013), precuneus atrophy (OR=0.94; p=0.022), “number of CSV pathologies” (β=-0.07; p<0.001) and “MRI-burden score” (β=-0.11; p<0.001), after adjustment for age and sex. The latter three were also associated with pulsatility and resistivity indexes.ConclusionsLow carotid end diastolic velocity, as well as increased carotid resistivity and pulsatility, were associated with signs of cerebral small vessel disease and patterns of brain atrophy, indicating a vascular component in the process of brain aging.     

Grandparental care and sleep disturbances in preschool children: a population-based prospective cohort study

ObjectivesSleep disturbances are common in preschoolers, and profoundly affected by parenting. Grandparents are increasingly involved in childcare and have attracted worldwide attention for their potential impacts on child well-being. However, no studies have explored child sleep health within the context of grandparental care. We aimed to explore the association between grandparents as primary caregivers and children's sleep disturbances.MethodsParticipants included 20,324 preschoolers from the Shanghai Children's Health, Education and Lifestyle Evaluation-Preschool (SCHEDULE-P) in Shanghai, China. They were initially assessed in November 2016 and were reassessed in April 2018 and April 2019. Children's primary caregivers were collected at each survey. Sleep disturbances were assessed by the Children's Sleep Habits Questionnaire (CSHQ).ResultsAt baseline, 84.4% of children had global sleep disturbances (CSHQ total score >41). Compared with parents, random-effects model indicated that grandparents as primary caregivers increased the adjusted odds ratio (OR) for children's global sleep disturbances by 30% (OR [95%CI]: 1.30 [1.21, 1.40]). To the specific domains of CSHQ, two-way repeated-measures ANOVA showed significant “caregiver transition” group × wave interaction in the behavioral sleep disturbances, such as “Bedtime Resistance” (p < 0.001). At each survey, children with grandparents as primary caregivers demonstrated significant higher behavioral sleep disturbances than their counterparts with parental care.ConclusionsGrandparental care is associated with increased sleep disturbances, particularly behavioral sleep disturbances, in preschoolers. Future studies should explore the underlying mechanisms and whether sleep programs targeting grandparents can decrease children's sleep disturbances.     

A standardized nomenclature for spectrogram EEG patterns: Inter-rater agreement and correspondence with common intensive care unit EEG patterns

ObjectiveTo determine the inter-rater agreement (IRA) of a standardized nomenclature for EEG spectrogram patterns, and to estimate the probability distribution of ictal-interictal continuum (IIC) patterns vs. other EEG patterns within each category in this nomenclature.MethodsWe defined seven spectrogram categories: “Solid Flames”, “Irregular Flames”, “Broadband-monotonous”, “Narrowband-monotonous”, “Stripes”, “Low power”, and “Artifact”. Ten electroencephalographers scored 115 spectrograms and the corresponding raw EEG samples. Gwet's agreement coefficient was used to calculate IRA.ResultsSolid Flames represented seizures or IIC patterns 69.4% of the time. Irregular Flames represented seizures or IIC patterns 38.7% of the time. Broadband-monotonous primarily corresponded with seizures or IIC (54.3%) and Narrowband-monotonous with focal or generalized slowing (43.8%). Stripes were associated with burst-suppression (37.2%) and generalized suppression (34.4%). Low Power category was associated with generalized suppression (94%). There was “near perfect” agreement for Solid Flames (κ = 94.36), Low power (κ = 92.61), and Artifact (κ = 93.72). There was “substantial agreement” for all other categories (κ = 74.65–79.49).ConclusionsThis EEG spectrogram nomenclature has high IRA among electroencephalographers.SignificanceThe nomenclature can be a useful tool for EEG screening. Future studies are needed to determine if using this nomenclature shortens time to IIC identification, and how best to use it in practice to reduce time to intervention.     

Associations between dimensions of mental health literacy and adolescent help-seeking intentions

Background

The majority of long-term mental health problems begin during adolescence. Low mental health literacy (MHL) may impede help-seeking for these problems. Although MHL is a multidimensional construct and adolescent help-seeking can be through formal and informal means, little is known about how dimensions of MHL influence these help-seeking intentions. This study examines associations between dimensions of MHL and formal and informal help-seeking intentions among adolescents. It also investigates whether informal help-seeking mediates the association between dimensions of MHL and formal help-seeking, and whether these associations are moderated by gender.

Methods

A cross-sectional survey including measures of MHL, and help-seeking intentions was distributed to participants in 10 schools (12–17 years) across Scotland (n = 734). Data were analysed using Confirmatory Factor Analyses (CFA) and Structural Equation Modelling (SEM).

Results

Confirmatory Factor Analyses identified two distinct dimensions of MHL: ability to identify a mental health problem, and knowledge of treatment efficacy. Only knowledge of treatment efficacy was associated with increased intention to seek formal and informal help. Ability to identify a mental health problem was negatively associated with both forms of help-seeking intentions. Informal help-seeking mediated the association between both forms of MHL and formal help-seeking. Gender did not moderate the associations between MHL and help-seeking.

Conclusions

Care should be taken when providing MHL interventions to ensure that adaptive forms of MHL are promoted. Future research should investigate possible mechanisms by which discrete forms of MHL influence adolescent help-seeking as well as investigating other potential moderators of MHL and help-seeking, such as stigma.     

Insomnia as a predictor of diagnosed memory problems: 2006–2016 Health and Retirement Study

ObjectiveTo evaluate the longitudinal relationship in insomnia symptoms over time with incident memory problems and dementia diagnoses among U.S. adults aged 65 years and older.MethodsSecondary analyses were performed on 9518 elderly participants (≥65 years) who completed the 2006 wave of the Health and Retirement Study (HRS) and were followed-up to determine if insomnia symptom scores (2006–2014) were associated with time-to-onset of [1] physician-diagnosed “memory-related disease”, “Alzheimer's disease” and/or “dementia, senility or any other serious memory impairment” and [2] diagnosis of dementia based on HRS-specific criteria. Cox proportional hazards models were constructed adjusting for socio-demographic, lifestyle, and health characteristics.ResultsIn fully adjusted models, severe insomnia symptoms were associated with increased risk of physician-diagnosed memory problems. Individuals reporting any change (increase or decrease) in insomnia symptoms during the 2006–2010 period were more likely to be diagnosed with dementia based on HRS criteria. Finally, those who experienced an increase in the severity of insomnia symptoms over time exhibited 41–72% increased risks of physician-diagnosed memory problems and 45–58% increased risks of dementia diagnosis based on HRS criteria.ConclusionsWhen severe insomnia symptoms increased over time, physician-diagnosed memory problems and dementia diagnoses also increased among U.S. elderly people over a 10-year follow-up period. More studies are required to confirm these findings using large prospective cohort designs and validated tools.     

Relationship between circadian typology and risk-taking behaviors in adolescents: A cross-sectional study

ObjectiveThis study examined the relationship between circadian typology and risk-taking behavior.MethodsA cross-sectional study was conducted, involving 755 primary and junior school students aged 11–16 years. The Adolescent Risk-Taking Questionnaire and Morningness-Eveningness Questionnaire were administered to assess risk-taking behavior and circadian typology, respectively. Multiple linear regression analyses were performed to analyze the factors influencing risk-taking behavior.ResultsCircadian typology was negatively correlated with risk-taking behavior, with age and sex controlled for (Model 1). When family and class circumstances were added in Model 2, the significance of the association persisted (β = −1.67, 95% CI: [−2.93, −0.42], P = .009). However, the association between circadian typology and risk-taking behavior showed no significance (P = 0.050) when personality characteristics were controlled for in Model 3.ConclusionsThese results provide evidence indicating a relationship between circadian typology and risk-taking behavior, suggesting that evening circadian type is a risk factor for risk-taking behavior in adolescents.     

A case of delayed diagnosis of Becker muscular dystrophy due to underlying developmental disorders

BackgroundDevelopmental disorders associated with Becker muscular dystrophy (BMD), possibly resulting from a lack of dystrophin in the brain, have been reported, but their importance is not fully understood. We report a case of a BMD patient who had been socially withdrawn due to mental retardation and autism spectrum disorder and could not receive appropriate medical services, resulting in delayed detection of severe cardiomyopathy and embolic strokes which developed as complications of BMD.Case report: The case is a 41-year-old male. In elementary school, he was the slowest runner in his class and had poor grades. He started missing school due to bullying in junior high school and had been socially withdrawn for 24 years. He developed difficulty walking due to progressive muscle weakness in the extremities and lost ambulation at age 36. At age 41, he was referred to our hospital by public health support services to address his social withdrawal. Muscle biopsy led to the diagnosis of BMD. Psychological examination revealed mild mental retardation and autism spectrum disorder, which may have resulted in social isolation. He had severe cardiomyopathy and asymptomatic cerebral infarction due to heart failure.ConclusionIn BMD patients, developmental disorders can potentially hinder access to appropriate medical treatment. BMD is an important differential diagnosis for physically disabled children with developmental disorders. Early intellectual and psychological interventions and evaluation of complications are important for improving patient prognosis and quality of life.     

A meta-analysis of the relationship between subjective sleep and depressive symptoms in adolescence

BackgroundAdolescence is a risk period for the development of mental illness, as well as a time for pronounced change in sleep behaviour. While prior studies, including several meta-analyses show a relationship between sleep and depressive symptoms, there were many inconsistences found in the literature.ObjectiveTo investigate the relationship between subjective sleep and depressive symptoms.MethodsFollowing PRISMA guidelines, we conducted a literature search that yielded forty-nine recent studies (2014–2020) with adolescent samples aged 9 to 25-year-olds, and more than double the sample size of previous meta-analyses (N = 318,256).ResultsIn a series of meta-analyses, we show that while several common categories of subjective sleep are associated with depressive symptoms in adolescents, the strength of this relationship varies. Measures of sleep perception: poor sleep quality (r = 0.41), insomnia (r = 0.37), sleep disturbances (r = 0.36), wake after sleep onset (r = 0.31), and daytime sleepiness (r = 0.30) correlated more strongly with depressive symptoms, than measures of sleep behaviour: sleep latency (r = 0.22), and sleep duration (r = −0.19).ConclusionsThese findings suggest that in studies of depressive symptoms it may be important to assess an adolescent's perception about their sleep, in addition to their sleep/wake behaviours.     

Mental health literacy about depression and schizophrenia among adolescents in Sweden

BackgroundMental health literacy (MHL) refers to an individual's knowledge of mental disorders, including the ability to recognize psychopathology and being aware of help options. Most studies of MHL have focused on adults.ObjectiveThe purpose of this study was to examine levels of MHL among adolescents.MethodsMHL was examined using two pre-established vignettes that presented an adolescent with symptoms of either depression or schizophrenia. The respondents were 426 adolescents (age mean = 16). Vignette data were analyzed both qualitatively and quantitatively.ResultsThe data showed that 42.7% and 34.7% of the respondents identified depression and schizophrenia, respectively. Depression was recognized more often by females than males. Professional help was suggested by a minority of the respondents for managing symptoms of depression (22.5%) or schizophrenia (32.6%). Altruistic behaviors, examined through the willingness to help an acquaintance with mental illness symptoms, were apparent among 58.2% of the respondents and to a greater extent in females than males. Answers following the schizophrenia vignette also revealed stigmatizing attitudes in 11.5% of the participants.ConclusionsThere are relatively low levels of MHL among teenagers in Sweden. Awareness campaigns and the implementation of psychoeducation in the school curriculum could increase MHL in this group.     

Theta-burst versus 20 Hz repetitive transcranial magnetic stimulation in neuropathic pain: A head-to-head comparison

ObjectiveHigh-frequency repetitive transcranial magnetic stimulation (rTMS) has been shown to reduce neuropathic pain, but intermittent “theta-burst” stimulation (iTBS) could be a better alternative because of shorter duration and greater ability to induce cortical plasticity. Here we compared head-to-head the pain-relieving efficacy of the two modalities when applied daily for 5 days to patients with neuropathic pain.MethodsForty-six patients received 20 Hz-rTMS and/or iTBS protocols and 39 of them underwent the full two procedures in a random cross-over design. They rated pain intensity, sleep quality, fatigue and general health status daily during 5 consecutive weeks.ResultsPain relief during the month following stimulation was superior after 20 Hz-rTMS relative to iTBS (F(1,38) = 4.645; p = 0.037). Correlation between respective levels of maximal relief showed a significant deviation toward the 20 Hz-rTMS effect. A greater proportion of individuals responded to 20 Hz-rTMS (52% vs 32%, 95 %CI[0.095–3.27]; p = 0.06), and reports of fatigue significantly improved after 20 Hz-rTMS relative to iTBS (p = 0.01). General health and sleep quality scores did not differentiate both techniques.ConclusionsHigh-frequency rTMS appeared superior to iTBS for neuropathic pain relief.SignificanceAdequate matching between the oscillatory activity of motor cortex and that of rTMS may increase synaptic efficacy, thus enhancing functional connectivity of motor cortex with distant structures involved in pain regulation.     

The “Connectivity Epileptogenicity Index ” (cEI), a method for mapping the different seizure onset patterns in StereoElectroEncephalography recorded seizures

ObjectiveLocalization of epileptogenic brain regions is a crucial aim of pre-surgical evaluation of patients with drug-resistant epilepsy. Several methods have been proposed to identify the seizure onset zone, particularly based on the detection of fast activity. Most of these methods are inefficient to detect slower patterns of onset that account for 20–30% of commonly observed Stereo-Electro-Encephalography (SEEG) patterns. We seek to evaluate the performance of a new quantified measure called the Connectivity Epileptogenicity Index (cEI) in various types of seizure onset patterns.MethodsWe studied SEEG recorded seizures from 51 patients, suffering from focal drug-resistant epilepsy. The cEI combines a directed connectivity measure (“out-degrees”) and the original epileptogenicity index (EI). Quantified results (Out-degrees, cEI and EI) were compared to visually defined seizure onset zone (vSOZ). We computed recall (sensitivity) and precision (proportion of correct detections within all detections) with vSOZ as a reference. The quality of the detector was quantified by the area under the precision-recall curve.ResultsBest results (in terms of match with vSOZ) were obtained for cEI. For seizures with fast onset patterns, cEI and EI gave comparable results. For seizures with slow onset patterns, cEI gave a better estimation of the vSOZ than EI.ConclusionsWe observed that cEI discloses better performance than EI when seizures starts with slower patterns and equal to EI in seizures with fast onset patterns.SignificanceThe cEI is a promising new tool for epileptologists, that helps characterizing the seizure onset zone in sEEG, in a robust way despite variations in seizure onset patterns.     

Association between eveningness preference,socio-behavioral factors,and insomnia symptoms in Korean adolescents

Objective/BackgroundStudies focusing on insomnia in adolescents are relatively scarce compared to those on excessive daytime sleepiness. We aimed to investigate the prevalence of insomnia symptoms and associated factors in Korean high school students.Patients/methodsA total of 8565 students (girls: 4104) were investigated nationwide, across 15 South Korean districts using an online self-report questionnaire. Insomnia symptoms were evaluated using the Global Sleep Assessment Questionnaire. The participants’ mean age was 16.77 ± 0.85 years.ResultsThe prevalence of insomnia symptoms was 39.43% (n = 3377). Logistic regression was used to estimate the odds ratio (OR) of insomnia symptoms associated with sleep characteristics and social behaviors after adjusting for the relevant covariates. Evening preference (OR, 2.51, 95% CI, 2.20–2.86), perception of insufficient sleep (OR, 3.55, 95% CI, 3.11–4.06), snoring usually/always (OR, 1.25; 95% CI, 1.00–1.55), witnessed sleep apnea usually/always (OR, 1.70; 95% CI, 1.17–2.46), increased internet addiction (OR, 1.02; 95% CI, 1.02–1.03), bad sleep environment (OR, 1.77; 95% CI, 1.50–2.10), ≥3 private extra classes (OR, 1.23; 95% CI, 1.01–1.49), often coffee consumption (OR, 1.31; 95% CI, 1.10–1.56), and often nocturnal eating (OR, 1.24; 95% CI, 1.06–1.45) were associated with insomnia symptoms. Evening preference (OR, 3.48; 95% CI, 2.52–4.82) was also associated with insomnia symptoms in the perceived sufficient sleep subgroup.ConclusionInsomnia symptoms were common in Korean high school students. Evening preference was the major factor associated with insomnia symptoms. Various socio-behavioral factors were also associated with insomnia symptoms.     

Development and validation of the hypersomnia-specific beliefs scale

Objective/BackgroundPatients with Central hypersomnia, especially Narcolepsy type 1 and Idiopathic Hypersomnia (NT1 and IHS) often have psychological frustration in their daily lives. We aimed to develop the first scale of hypersomnia-specific beliefs (HSB).Patients/methodsWe developed the HSB scale consisting of three factors (“aversion toward doze”, “hypersensitivity toward others” reactions about my doze”, and “sense of defeat caused by doze”) with 12 items through interviews to 11 patients with NT1 and IHS. Validity and reliability of the HSB were evaluated cross-sectionally with 166 patients with NT1 and IHS and 375 controls. Simultaneously, scores of patient health questionnaire −2(PHQ-2), mini-Social Phobia Inventory (mini-SPIN), and Epworth Sleepiness Scale (ESS) were obtained.ResultsThis 3-factor model had enough fitness (χ2 = 60.25, df = 51, p = 0.18, TLI = 0.99, CFI = 0.99, RMSEA = 0.03), Cronbach's α coefficient being 0.90. The intraclass correlation coefficient was 0.76. Also, the area under the receiver operating characteristic curve (AUC = 0.88) confirmed good discrimination ability. A cut-off score of 38 resulted in a sensitivity of 90% and a specificity of 75%. Multiple linear regression analyses showed that these scales were independently associated with the HSB score; the PHQ-2 (β = 0.24, p = 0.002), mini-SPIN (β = 0.29, p < 0.001) and ESS (β = 0.15, p = 0.048).ConclusionsOur data suggest that the HSB scale measured beliefs in NT1 and IHS patients with good validity, reliability, and discrimination ability. The HSB scale assesses the negative beliefs specific to patents with NT1 and IHS. This scale could be applied to the development of novel psychotherapeutic approach to patients with NT1 and IHS.     

Social jetlag is associated with cardiorespiratory fitness in male but not female adolescents

IntroductionCardiorespiratory fitness (CRF) is a vital sign that can improve risk classification for adverse health outcomes. While lifestyle-related factors are associated with CRF, few have examined the influence of sleep characteristics, especially in youths. Social jetlag, a mismatch between one's biological clock and sleep schedule, is prevalent in adolescents and associated with increased adiposity, though its relationship with CRF is unclear.ObjectiveTo quantify the relationship between social jetlag and CRF, independent of other sleep characteristics.MethodsThis cross-sectional sample includes 276 New Zealand adolescents (14–18 years, 52.5% female). CRF (VO_2max) was estimated from a 20-m multi-stage shuttle run. Average sleep duration, sleep disturbances, social jetlag, physical activity, and the number of bedroom screens were estimated from validated self-report surveys. Social jetlag is the difference in hours between the midpoint of sleep during weekdays (school) and weekend days (free). Combined and sex-stratified linear regression assessed the association between sleep outcomes and CRF, controlling for relevant covariates.ResultsMales slept 17.6 min less, had less sleep disturbances, and a 25.1-min greater social jetlag than their female peers (all p < 0.05). A 1-h increase in social jetlag was associated with a 0.72 ml/kg/min decrease in VO_2max (95% CI: −1.31, −0.14), independent of other sleep variables, which were not associated with CRF. Sex-specific models indicated an association in males (B −0.93, 95% CI: −1.76, −0.09), but not females (B −0.32, 95% CI: −1.18, 0.55).ConclusionsSocial jetlag is negatively associated with CRF in adolescent males and may be a simple, measurable target for public health interventions.