Jane M. Onoye

Changes in PTSD symptomatology and mental health during pregnancy and postpartum.

Changes in mental health symptoms throughout pregnancy and postpartum may impact a woman’s experience and adjustment during an important time. However, few studies have investigated these changes throughout the perinatal period, particularly changes in posttraumatic stress disorder (PTSD) symptoms. The purpose of this study was to examine longitudinal changes in PTSD, depression, and anxiety symptomatology during pregnancy and postpartum. Pregnant women of ethnically diverse backgrounds receiving services for prenatal care at an outpatient obstetric-gynecology clinic or private physicians’ office were assessed by interview on symptoms of PTSD, depression, anxiety, and general stress up to four times, including their first, second, and third trimester, and postpartum visits. Overall, during pregnancy there was a declining trend of PTSD symptoms. For anxiety, there was no overall significant change over time; however, anxiety symptoms were individually variable in the rate of change. For both depression and general stress symptoms, there was a declining trend, which was also variable in the individual rate of change among women during their pregnancy. Visual and post hoc analyses also suggest a possible peak in PTSD symptoms in the weeks prior to delivery. While most mental health symptoms may generally decrease during pregnancy, given the individual variability among women in the rate of change in symptoms, screening and monitoring of symptom fluctuations throughout the course of pregnancy may be needed. Further studies are needed to examine potential spiking of symptoms in the perinatal period.

Mental Health During Pregnancy: A Study Comparing Asian, Caucasian and Native Hawaiian Women

Objective: This study examines perinatal mental health issues, ethnic differences, and comorbidity among pregnant women in Hawaii. Methods: Eighty-four participants were recruited from women, ages 18–35, seeking prenatal care on Oahu. They were interviewed at their initial prenatal visit about substance use, depression, and anxiety. Results: Sixty-one percent of women screened positive for at least one mental health issue. Thirteen percent of all pregnant women reported drinking during pregnancy with 5% reporting problem drinking, 15% reported smoking cigarettes on a regular basis, 5% of pregnant women had probable depression, and 13% of pregnant women had probable anxiety. Significant ethnic differences were found in cigarette smoking, with the highest rate among Native Hawaiian women (35%). Native Hawaiian women were also more likely to binge drink. Conclusion: Given the high rates of potential mental health issues in our sample, our findings highlight the importance of screening and treatment for mental health issues early in pregnancy in Hawaii.

Use of incentives and web-based administration for surveying student alcohol and substance use in an ethnically diverse sample

With increasing burden on schools and requirements for active parental consent, low student survey participation rates are problematic, including where ethnic minority students are often underrepresented in behavioural risk surveys. To improve parent permission rates and survey participation, incentive use (individual vs. group) and mode of survey administration (web-based vs. paper–pencil) were examined in a sample of ethnically diverse students (n = 2488) in the 6th, 8th, 10th and 12th grades from eight schools in Hawai‘i. Mode of survey administration was also compared for student reporting of alcohol and other substance use and associated risk and protective factors. Classes were assigned to one of four conditions based on incentive type and route of survey administration. The group incentive was associated with a significantly higher rate of parental permission compared to individual incentive; however, it did not impact survey completion rate. Students who took the web-based version compared to the paper–pencil version of the survey were more likely to report use of alcohol, tobacco and other drugs in the past 12 months. The use of web-based surveys may increase reporting of sensitive behaviours such as substance use among adolescents compared to paper–pencil versions.

Sociodemographic Characterization of ECT Utilization in Hawaii

Objectives Minimal research has been done on sociodemographic differences in utilization of electroconvulsive therapy (ECT) for refractory depression, especially among Asian Americans and Pacific Islanders. Methods This study examined sociodemographic and diagnostic variables using retrospective data from Hawaii, an island state with predominantly Asian Americans and Pacific Islanders. Retrospective data were obtained from an inpatient and outpatient database of ECT patients from 2008 to 2010 at a tertiary care community hospital on O’ahu, Hawaii. Results There was a significant increase in overall ECT utilization from 2008 to 2009, with utilization remaining stable from 2009 to 2010. European Americans (41%) and Japanese Americans (29%) have relatively higher rates of receiving ECT, and Filipino Americans and Native Hawaiians have relatively lower rates in comparison with their population demographics. Japanese Americans received significantly more ECT procedures than European Americans. Conclusions Electroconvulsive therapy is underutilized by certain sociodemographic groups that may benefit most from the treatment. There are significant differences in ECT usage based on ethnicity. Such differences may be related to help-seeking behavior, economic differences, and/or attitudes regarding mental illness. Further research is needed to elucidate the reasons for differences in utilization.

Multilevel Factor Analyses of Family Data from the Hawai'i Family Study of Cognition.

In this study, we reanalyzed the classic Hawai’i Family Study of Cognition (HFSC) data using contemporary multilevel modeling techniques. We used the HFSC baseline data (N = 6,579) and reexamined the factorial structure of 16 cognitive variables using confirmatory (restricted) measurement models in an explicit sequence. These models were initially fitted using multilevel confirmatory factor analysis techniques and the invariant six-factor models with two higher order factors fit fairly well (εa < 0.08) to the total, between- and within-family data. More crucially, a model requiring metric factorial invariance proved to be a reasonable fit to the between and within matrices, and allowed the ratio of the between-family variation to total family variation (eta-squared) to be calculated separately for each common factor (η2: Gc = .27, Gf = .22, Gm = .15, Gs = .04, Gv = .30, and SP = .16). Higher order factors were fitted using multilevel structural equation modeling techniques and these suggested a reasonable two-factor solution with unequal family impacts. These results suggest that (a) A “G only model” does not fit the data very well, and there are many sources of individual differences in cognitive abilities; (b) the sources of the individual differences in cognition can be measured the same way between and within families; and (c) even after the unique test components are removed, cognitive differences are larger within families than between families. We consider other general multivariate family models, and we raise questions about family influences.

Challenges and Progress in Building a Comprehensive Statewide System for Fetal Alcohol Spectrum Disorders Prevention in Hawai‘i

Introduction Fetal Alcohol Spectrum Disorders (FASD) has been a maternal and child public health concern in Hawaiʻi for over the past decade. Methods A historical assessment of FASD related activities was conducted to map the challenges and progress made in building a comprehensive statewide system for FASD prevention and intervention in an island state. Results Progress has primarily been reflected in increasing the number of individuals receiving FASD education and training, as well as some initiatives in public awareness. The creation of a State FASD Coordinator position was significant in catalyzing support for FASD initiatives and extending collaborative networks with national experts/teams, community-based organizations, and other local agencies to leverage resources in a time of economic strain. Major challenges and barriers included loss of the FASD Coordinator position, reliance on external resources and lack of local capacity for training and education integration into existing practice systems, and inadequate surveillance infrastructure. Discussion Lack of funding and resources were a common factor overall, and impeded the development of a state strategic plan which was needed to guide overall efforts and policies into a more coordinated system to reduce and prevent FASDs in Hawai‘i.

A model for evaluating academic research centers: Case study of the Asian/Pacific Islander Youth Violence Prevention Center

OBJECTIVES To provide one model for evaluating academic research centers, given their vital role in addressing public health issues. METHODS A theoretical framework is described for a comprehensive evaluation plan for research centers. This framework is applied to one specific center by describing the centers Logic Model and Evaluation Plan, including a sample of the centers activities. RESULTS Formative and summative evaluation information is summarized. In addition, a summary of outcomes is provided: improved practice and policy; reduction of risk factors and increase in protective factors; reduction of interpersonal youth violence in the community; and national prototype for prevention of interpersonal youth violence. CONCLUSIONS Research centers are important mechanisms to advance science and improve peoples quality of life. Because of their more infrastructure-intensive and comprehensive approach, they also require substantial resources for success, and thus, also require careful accountability. It is therefore important to comprehensively evaluate these centers. As provided herein, a more systematic and structured approach utilizing logic models, an evaluation plan, and successful processes can provide research centers with a functionally useful method in their evaluation.

Improving assessment of race, ethnicity, and culture to further veteran PTSD research.

Objective: Racial and ethnic disparities in posttraumatic stress disorder (PTSD) and its treatment have been documented for both civilians and military veterans. To better understand the presence of disparities and factors that might contribute to them, accurate assessment of race and ethnicity is critical; however there still remains unstandardized assessment and challenges to implementation. The authors highlight specific problems in the assessment of race and ethnicity in research, such as missing data, misclassification, classification categories too limited to reflect many people’s social identities, and inappropriate aggregation of ethnoracial subgroups. Conclusions: A proposal is made for a minimal uniform assessment standard of race and ethnicity. Additional recommendations incorporate principles proposed by the Institute of Medicine that allow for more granular assessment of race and ethnicity to better capture individual identity and cultural factors as they relate to the assessment, experience and management of PTSD.

Increased Elderly Utilization of Psychiatric Emergency Resources as a Reflection of the Growing Mental Health Crisis Facing Our Aging Population

The elderly population continues to soar in the United States, with the number of those older than 65 years expected to double from 2010 to 2050. Many are predicting an imminent mental health crisis for our seniors, as available resources lag further behind the demand. One contributing factor is the evergrowing number of individuals with dementia-related behavioral symptoms. In Hawaii, a top retirement destination known for longevity of life, we have experienced greater use by elderly patients of the psychiatric emergency department (ED) at the largest general hospital in the state. As evidence of this trend, we present age-specific psychiatric ED utilization patterns from 2007 to 2011, a period during which local resources for geriatric mental health had remained static. We collected data (age, mode of arrival, main diagnosis, length of stay [LOS], and disposition) for all psychiatric ED visits (N = 22,124) in the 5-year period. Patients were grouped as younger (aged <65 years) or older (aged ≥65 years, N = 1,370). Within this period, there was a general trend of more access by elderly patients, with yearly numbers and proportions at 234 (5.7%) in 2007, 220 (5.5%) in 2008, 301 (7.2%) in 2009, 298 (6.2%) in 2010, and 319 (6.5%) in 2011. A more pronounced and alarming progression was seen in law enforcement being increasingly relied upon, usually because of violent behavior, to bring older patients to the ED (12.5% in 2007, 11.0% in 2008, 16.9% in 2009, 18.4% in 2010, and 24.5% in 2011; χ(8) = 41.56, p < 0.01), whereas the numbers of those who arrived by ambulance (64.7%, 50.7%, 59.5%, 59.2%, 54.5%, respectively) or with caregivers/self (22.8%, 38.4%, 23.6%, 22.4%, 21.0%, respectively) trended downward. Behavior due to dementia of all types was recorded as the main presenting diagnosis among 14% of older patients. This number is likely much higher as we were unable to capture secondary diagnoses reliably. Using LOS to estimate ED utilization, older patients had longer LOS (median: 400 minutes) than younger patients (median = 351 minutes, U = 12,362,765, p < 0.01). Among older patients, those receiving medical admission (11% of all elderly visits) had the highest LOS (median: 519 minutes), followed by psychiatric admission (31%, median = 431 minutes) and discharge (58%, median = 352 minutes, KruskalWallis (df 2) = 76.43, p < 0.01; post-hoc medical > psychiatric > discharge). Further, highly advanced age (≥80 years defined as “older old”), compared with “younger old” (aged 65–79 years), was associated with an even greater LOS, but only among those who were psychiatrically admitted (F(2, 1364) = 5.36, p = 0.01, using log-transformed LOS because of positive skew), with the significant interaction term characterized by a median LOS of 457 minutes in “older old” and 409 minutes in “younger old”. Such findings were not surprising. Because of a shortage of geriatric mental health services, exhausted caregivers were often unwilling accept patients back from the ED (usually cases involving the oldest old), where they had to endure lengthy (often multi-day) searches for a limited number of appropriate psychiatric beds. Our observations reflect worrisome outcomes of a fairly stagnant geriatric mental health system, during a period in which growth of the elderly population outpaced other age groups. As a result, symptom acuity and potential for harm rose steadily, as indicated by more law enforcement being invoked by caregivers for transfer to the ED. Lack of acute placement options further worsened crowding in the ED, straining finite acute resources further. Our study period (2007–2011) ushers the very beginning of the baby boomer cohort becoming 65 years or older. Thus, the degree of reliance on ED behavioral services by seniors, especially those with dementia, and their caregivers is likely to increase. Long-term solutions to shore up widening gaps in geriatric mental health are becoming even more urgent.