Jitender Sareen

Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis

BACKGROUND Depression and anxiety are common in persons with multiple sclerosis (MS), and adversely affect fatigue, medication adherence, and quality of life. Though effective treatments for depression and anxiety exist in the general population, their applicability in the MS population has not been definitively established. OBJECTIVE To determine the overall effect of psychological and pharmacological treatments for depression or anxiety in persons with MS. METHODS We searched the Medline, EMBASE, PsycINFO, PsycARTICLES Full Text, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and Scopus databases using systematic review methodology from database inception until March 25, 2015. Two independent reviewers screened abstracts, extracted data, and assessed risk of bias and strength of evidence. We included controlled clinical trials reporting on the effect of pharmacological or psychological interventions for depression or anxiety in a sample of persons with MS. We calculated standardized mean differences (SMD) and pooled using random effects meta-analysis. RESULTS Of 1753 abstracts screened, 21 articles reporting on 13 unique clinical trials met the inclusion criteria. Depression severity improved in nine psychological trials of depression treatment (N=307; SMD: -0.45 (95%CI: -0.74, -0.16)). The severity of depression also improved in three pharmacological trials of depression treatment (SMD: -0.63 (N=165; 95%CI: -1.07, -0.20)). For anxiety, only a single trial examined psychological therapy for injection phobia and reported no statistically significant improvement. CONCLUSION Pharmacological and psychological treatments for depression were effective in reducing depressive symptoms in MS. The data are insufficient to determine the effectiveness of treatments for anxiety.

Association of Child Abuse Exposure With Suicidal Ideation, Suicide Plans, and Suicide Attempts in Military Personnel and the General Population in Canada

IMPORTANCE Recent evidence indicates a high prevalence of child abuse exposure in modern US veterans, which may explain in part their higher likelihood of suicide relative to civilians. However, the relationship between child abuse exposure and suicide-related outcomes in military personnel relative to civilians is unknown. Furthermore, the associations among deployment-related trauma, child abuse exposure, and suicide-related outcomes in military personnel have not been examined. OBJECTIVES To determine whether child abuse exposure is more prevalent in Canadian Armed Forces (CAF) personnel compared with the Canadian general population (CGP); to compare the association between child abuse exposure and suicidal ideation, suicide plans, and suicide attempts among the CAF and CGP; and to determine whether child abuse exposure has an additive or interaction effect on the association of deployment-related trauma and past-year suicidal ideation and suicide plans among Regular Forces personnel. DATA, SETTING, AND PARTICIPANTS Data were collected from the following 2 nationally representative data sets: the 2013 Canadian Forces Mental Health Survey (CFMHS) for the CAF (8161 respondents; response rate, 79.8%) and the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH) for the CGP (23,395 respondents; response rate, 68.9% [of these, 15,981 age-matched participants were drawn]). Data were collected from April 15 to August 31, 2013, for the CFMHS and January 2 to December 31, 2012, for the CCHS-MH. Data were analyzed from October 2014 to October 22, 2015. Statistical weights were applied to both data sets. MAIN OUTCOMES AND MEASURES Child abuse exposure, including physical abuse, sexual abuse, and exposure to intimate partner violence, and deployment-related trauma were assessed in relation to suicide-related outcomes. RESULTS Data were analyzed from 24 142 respondents aged 18 to 60 years (Regular Forces, 86.1% male and 13.9% female; Reserve Forces, 90.6% male and 8.9% female; and CGP, 49.9% male and 50.1% female). Any child abuse exposure was higher in the Regular Forces (47.7%; 95% CI, 46.4%-49.1%) and Afghanistan mission-deployed Reserve Forces (49.4%; 95% CI, 46.3%-51.5%) compared with the CGP (33.1%; 95% CI, 31.8%-34.4%). All types of child abuse exposures were associated with increased odds of suicidal ideation, suicide plans, and suicide attempts in the CGP (range of adjusted odds ratios [AORs], 3.0 [95% CI, 2.3-3.9] to 7.7 [95% CI, 5.7-10.3]; P < .05) and CAF (range of AORs, 1.7 [95% CI, 1.0-2.9] to 6.3 [95% CI, 4.2-9.5]; P < .05), with many associations significantly weaker in military personnel relative to civilians. Additive effects for past-year suicide ideation (AOR, 2.7; 95% CI, 1.8-4.2) and past-year suicide plans (AOR, 4.6; 95% CI, 2.3-9.2) but not interactive effects for past-year suicide ideation (AOR, 1.2; 95% CI, 0.7-2.2) and past-year suicide plans (AOR, 0.8; 95% CI, 0.3-2.2) were noted between deployment-related trauma and child abuse exposure among Regular Forces personnel. CONCLUSIONS AND RELEVANCE Individuals with a child abuse history may be more likely to enter the military, and child abuse exposure may increase the likelihood of suicide-related outcomes. Prevention efforts targeting child abuse may reduce suicide-related outcomes.

Childhood emotional maltreatment and mental disorders: results from a nationally representative adult sample from the United States

Child maltreatment is a public health concern with well-established sequelae. However, compared to research on physical and sexual abuse, far less is known about the long-term impact of emotional maltreatment on mental health. The overall purpose of this study was to examine the association of emotional abuse, emotional neglect, and both emotional abuse and neglect with other types of child maltreatment, a family history of dysfunction, and lifetime diagnoses of several Axis I and Axis II mental disorders. Data were from the National Epidemiological Survey on Alcohol and Related Conditions collected in 2004 and 2005 (n=34,653). The most prevalent form of emotional maltreatment was emotional neglect only (6.2%), followed by emotional abuse only (4.8%), and then both emotional abuse and neglect (3.1%). All categories of emotional maltreatment were strongly related to other forms of child maltreatment (odds ratios [ORs] ranged from 2.1 to 68.0) and a history of family dysfunction (ORs ranged from 2.2 to 8.3). In models adjusting for sociodemographic characteristics, all categories of emotional maltreatment were associated with increased odds of almost every mental disorder assessed in this study (adjusted ORs ranged from 1.2 to 7.4). Many relationships remained significant independent of experiencing other forms of child maltreatment and a family history of dysfunction (adjusted ORs ranged from 1.2 to 3.0). The effects appeared to be greater for active (i.e., emotional abuse) relative to passive (i.e., emotional neglect) forms of emotional maltreatment. Childhood emotional maltreatment, particularly emotionally abusive acts, is associated with increased odds of lifetime diagnoses of several Axis I and Axis II mental disorders.

Population‐based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies

The objective of this study was to detail the nature and correlates of mental health and non‐mental health care contacts prior to suicide death. We conducted a systematic extraction of data from records at the Office of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to 2011. Data on 2,835 suicide deaths were linked with provincial health administrative data to identify health care contacts during the 12 months prior to suicide. Sub‐populations of suicide decedents based on the presence and type of mental health care contact were described and compared across socio‐demographic, clinical and suicide‐specific variables. Time periods from last mental health contact to date of death were calculated and a Cox proportional hazards model examined covariates. Among suicide decedents, 91.7% had some type of past‐year health care contact prior to death, 66.4% had a mental health care contact, and 25.3% had only non‐mental health contacts. The most common type of mental health contact was an outpatient primary care visit (54.0%), followed by an outpatient psychiatric visit (39.8%), an emergency department visit (31.1%), and a psychiatric hospitalization (21.0%). The median time from last mental health contact to death was 18 days (interquartile range 5‐63). Mental health contact was significantly associated with female gender, age 25‐64, absence of a psychosocial stressor, diagnosis of schizophrenia or bipolar disorder, past suicide attempt, self‐poisoning method and absence of a suicide note. Significant differences between sub‐populations of suicide decedents based on the presence and nature of their health care contacts suggest the need for targeting of community and clinical‐based suicide prevention strategies. The predominance of ambulatory mental health care contacts, often close to the time of death, reinforce the importance of concentrating efforts on embedding risk assessment and care pathways into all routine primary and specialty clinical care, and not only acute care settings.

Mental health outcomes of burn: a longitudinal population-based study of adults hospitalized for burns

PURPOSE This study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design. METHODS Adult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics. RESULTS While the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time. CONCLUSIONS Although burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population.

High burden of subthreshold DSM-5 post-traumatic stress disorder in U.S. military veterans

A substantial proportion of individuals worldwide develop post‐traumatic stress disorder (PTSD) following exposure to traumatic events1, 2, 3. Although the epidemiology of PTSD has been widely studied1, 2, 3, fewer studies have examined subthreshold PTSD, defined as experiencing clinically significant symptoms of PTSD but not meeting full diagnostic criteria for the disorder. With the field of psychiatry increasingly moving towards a dimensional perspective of mental disorders, it is important to understand the burden of subthreshold manifestations of these disorders. The lifetime prevalence of subthreshold PTSD has ranged from 3.6 to 25.6%2, 4, 5, 6. While not a formal diagnosis, subthreshold PTSD is associated with elevated rates of comorbid psychiatric disorders, suicidality, and physical health problems compared to trauma‐exposed individuals without subthreshold or threshold PTSD2, 4, 5, 6. To date, however, only two studies have examined the epidemiology of subthreshold PTSD as defined using the DSM‐5. The first analyzed data from the World Health Organization World Mental Health Surveys and found that the prevalence of subthreshold PTSD ranged from 0.7 to 4.6%, depending on the definition used. Further, individuals with subthreshold PTSD were 2.5‐5 times more likely to have a comorbid mood or anxiety disorder compared to trauma‐exposed controls7. This study was limited by the operationalization of PTSD, which was derived from a DSM‐IV module and did not include the new DSM‐5 symptoms. The second study of a national sample of Vietnam veterans found that the prevalence of current subthreshold PTSD ranged from 1.9 to 5.7%, and that the comorbidity between DSM‐5 subthreshold PTSD and comorbid disorders ranged from 0.7 to 30.9%8. While these studies provide important insight into the prevalence and correlates of subthreshold DSM‐5 PTSD, additional population‐based data are needed to better understand the burden of this condition. We analyzed data from the National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally representative cohort of U.S. military veterans, to examine the prevalence and clinical correlates of DSM‐5 subthreshold PTSD. The NHRVS, conducted in 2013, surveyed 1,484 veterans aged 20+. The sample was ascertained from KnowledgePanel, a nationally representative survey research panel representing approximately 98% of U.S. households. Post‐stratification weights were applied to permit generalizability of results to the U.S. veteran population. Study constructs were assessed with the following tools: Trauma History Screen, PTSD Checklist for DSM‐5 (PCL‐5)9, Mini International Neuropsychiatric Interview and Patient Health Questionnaire‐4 for lifetime and current psychopathology, respectively, Fagerstrom Test for Nicotine Dependence, and Short Form‐8 (SF‐8) Health Survey for mental and physical functioning10. Lifetime PCL‐5 responses were used to create a three‐group variable: a) no/low PTSD symptoms (defined as endorsement of ≤1 PTSD criteria B‐E at a severity of “moderate” or higher); b) subthreshold DSM‐5 PTSD (defined as endorsement of 2 or 3 B‐E criteria, or all 4 B‐E criteria but not 1 month symptom duration and/or functional impairment); and c) probable lifetime DSM‐5 PTSD (defined as meeting criteria A‐G for PTSD). A comparable three‐level variable was created for past‐month PTSD symptoms, with a score ≥38 on the PCL‐5 distinguishing between subthreshold and probable PTSD in the absence of past‐month symptom duration and functional impairment assessment in the NHRVS. Weighted prevalence of lifetime and past‐month subthreshold DSM‐5 PTSD was computed in the full sample (N=1,478; 6 subjects had missing data). Other analyses were conducted in only trauma‐exposed veterans (N=1,268). Logistic regression and multivariable analyses of covariance were conducted to examine associations of probable and subthreshold PTSD with comorbid psychiatric disorders and SF‐8 scores. Analyses were adjusted for socio‐demographic variables, combat veteran status, number of lifetime traumas, and any lifetime mental disorder. The lifetime and past‐month prevalence of subthreshold PTSD was 22.1% and 13.5%, respectively, and higher than the prevalence of lifetime (8.0%) and past‐month (4.5%) probable PTSD. The prevalence of lifetime subthreshold PTSD was higher in women than in men (30.3% vs. 21.2%, X2=10.3, p=0.006) and, although the prevalence of lifetime probable PTSD decreased across age groups (20.8% in 18‐34 year olds to 1.9% in 75+ year olds), the prevalence of subthreshold PTSD remained relatively stable across all but the 75+ age group (21.1% to 26.6%). Lifetime subthreshold PTSD was associated with a greater likelihood of all lifetime (i.e., major depressive, social anxiety, alcohol and drug use disorders) and current (i.e., major depressive and generalized anxiety disorders, suicidal ideation) psychiatric outcomes, except nicotine dependence, relative to veterans reporting no/low symptoms (adjusted odds ratio, AOR range from 1.7 for lifetime alcohol use disorder to 4.9 for current generalized anxiety disorder). Veterans with probable PTSD had a greater likelihood of all outcomes relative to veterans with no/low symptoms, and these associations were numerically larger in magnitude relative to the subthreshold PTSD group (AOR range from 1.9 for lifetime nicotine dependence to 19.3 for current generalized anxiety disorder). Although individuals with probable PTSD reported the poorest functioning (d range from 0.31 for health rating to 1.45 for mental health), veterans with subthreshold PTSD also reported significantly worse functioning than veterans with no/low PTSD symptoms on all SF‐8 measures (d range from 0.12 for health rating to 0.41 for mental health and social functioning). A similar pattern of findings was observed in analyses of past‐month subthreshold and probable PTSD. The results of this study suggest that a strikingly high proportion of U.S. veterans – approximately one in three – experience clinically significant PTSD symptoms in their lifetime. They further suggest that subthreshold PTSD is associated with an elevated burden of comorbid psychiatric disorders, as well as decrements in mental and physical functioning. While the field has not reached a consensus regarding the operationalization of subthreshold PTSD, these results underscore the importance of assessment, prevention and treatment efforts in targeting veterans and other trauma‐affected individuals with PTSD symptoms below the diagnostic threshold. Natalie P. Mota1, Jack Tsai2,3, Jitender Sareen4, Brian P. Marx5, Blair E. Wisco6, Ilan Harpaz‐Rotem3,7, Steven M. Southwick3,7, John H. Krystal3,7, Robert H. Pietrzak3,7 1Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada; 2U.S. Department of Veterans Affairs, New England Mental Illness Research, Education, and Clinical Center, West Haven, CT, USA; 3Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; 4Departments of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Canada; 5U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, and Division of Psychiatry, Boston University School of Medicine, Boston, MA, USA; 6Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC, USA; 7U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA

Purpose in Life is Associated with a Reduced Risk of Incident Physical Disability in Aging U.S. Military Veterans.

OBJECTIVES The current study evaluated the incidence and determinants of physical disability in a contemporary, nationally representative sample of U.S. military veterans. DESIGN, SETTING, PARTICIPANTS Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative, prospective cohort study of 1,686 veterans aged 55 years and older. Waves 1 and 2 were conducted in 2011 and 2013, respectively. MEASUREMENTS Potential determinants of incident disability in activities of daily living (ADL; e.g., bathing, dressing) and instrumental activities of daily living (IADL; e.g., food preparation, medication adherence) were assessed at Wave 1, and included sociodemographic characteristics, and risk (e.g., medical conditions, psychiatric distress), and protective psychosocial (e.g., psychological resilience, purpose in life) factors. RESULTS The two-year incidence of any physical disability (ADL or IADL) among veterans aged 55 years and older was 11.5%, and the incidence of ADL and IADL disability was 3.0% and 11.4%, respectively. Older age, being married/cohabiting, and number of medical conditions-specifically, diabetes, heart attack, and chronic pain-were associated with an increased risk of any incident physical disability and incident IADL disability (adjusted odds ratio [AOR] range: 1.10-3.10). Retirement was associated with an increased risk of incident ADL disability (AOR: 7.53, 95% CI: 1.37-41.51). Purpose in life was found to be protective for incident IADL disability (AOR: 0.93, 95% CI: 0.87-0.99). CONCLUSIONS Although greater medical burden is associated with increased incidence of physical disability in U.S. veterans, results of this study suggest that initiatives designed to foster greater purpose in life may help protect against the development of physical disability in this rapidly growing segment of the population.

A Longitudinal Study of the Temporal Relation Between Problem Gambling and Mental and Substance Use Disorders Among Young Adults

Objective: Relatively little is known about the temporal relation between at-risk gambling or problem gambling (PG) and mental and substance use disorders (SUDs) in young adulthood. Our study aimed to examine whether past-year, at-risk, or PG is associated with incident mental disorders and SUDs (that is, depression, generalized anxiety disorder, obsessive–compulsive disorder [OCD], or alcohol dependence) and illegal drug use, and whether past-year mental disorders and SUDs and illegal drug use is associated with incident at-risk or PG. Method: Data for this longitudinal study were drawn from the Manitoba Longitudinal Study of Young Adults (MLSYA). Respondents aged 18 to 20 years in 2007 were followed prospectively for 5 years. Results: In cross-sectional analyses, at-risk or PG was associated with increased odds of depression, OCD, alcohol dependence, and illegal drug use. In longitudinal analysis at-risk or PG at cycle 1 was associated with incident major depressive disorder, alcohol dependence, and illegal drug use in the follow-up period. Only illegal drug use at cycle 1 was associated with incident at-risk or PG during follow-up. Conclusions: At-risk or PG was associated with more new onset mental disorders and SUDs (depression, alcohol dependence, and illegal drug use), compared with the reverse (illegal drug use was the only association with new onset at-risk or PG). Preventing at-risk or PG from developing early in adulthood may correspond with decreases in new onset mental disorders and SUDs later in adulthood.

Linking typologies of childhood adversity to adult incarceration: findings from a nationally representative sample

Ecologically valid typologies of adverse child experiences (ACEs) were identified to investigate the link between ACEs and adult incarceration. In a nationally representative sample (N = 34,653, age 20+), latent class analysis (LCA) was conducted with childhood maltreatment (physical, sexual, and emotional abuse, interpersonal violence [IPV] exposure, physical neglect) and caregiver maladjustment (substance use, incarceration, mental illness, and suicidal behavior) indicators. LCA identified a 5-typology model (1. Low Adversity Risk; 2. Caregiver Substance Use, and Maltreatment Acts of Omission; 3. Physical and Emotional Maltreatment; 4. Severe Cross-Subtype Maltreatment and Caregiver Substance Use; and 5. Caregiver Maladjustment). Controlling for sociodemographics and substance use problems, logistic regression analyses determined that, compared with the Low Adversity Risk typology, all typologies (except Caregiver Maladjustment) had elevated incarceration risk (adjusted odds ratios: 1.76–4.18). Maltreatment experiences were more predictive of incarceration for women versus men. Childhood maltreatment confers risk for incarceration beyond established risk factors, but caregiver maladjustment, alone, does not. Preventative efforts should focus on understanding and targeting pathways to delinquency for individuals with childhood maltreatment.

Development and validation of a risk prediction algorithm for the recurrence of suicidal ideation among general population with low mood

BACKGROUND Suicidal ideation is one of the strongest predictors of recent and future suicide attempt. This study aimed to develop and validate a risk prediction algorithm for the recurrence of suicidal ideation among population with low mood METHODS 3035 participants from U.S National Epidemiologic Survey on Alcohol and Related Conditions with suicidal ideation at their lowest mood at baseline were included. The Alcohol Use Disorder and Associated Disabilities Interview Schedule, based on the DSM-IV criteria was used. Logistic regression modeling was conducted to derive the algorithm. Discrimination and calibration were assessed in the development and validation cohorts. RESULTS In the development data, the proportion of recurrent suicidal ideation over 3 years was 19.5 (95% CI: 17.7, 21.5). The developed algorithm consisted of 6 predictors: age, feelings of emptiness, sudden mood changes, self-harm history, depressed mood in the past 4 weeks, interference with social activities in the past 4 weeks because of physical health or emotional problems and emptiness was the most important risk factor. The model had good discriminative power (C statistic=0.8273, 95% CI: 0.8027, 0.8520). The C statistic was 0.8091 (95% CI: 0.7786, 0.8395) in the external validation dataset and was 0.8193 (95% CI: 0.8001, 0.8385) in the combined dataset. LIMITATIONS This study does not apply to people with suicidal ideation who are not depressed. CONCLUSIONS The developed risk algorithm for predicting the recurrence of suicidal ideation has good discrimination and excellent calibration. Clinicians can use this algorithm to stratify the risk of recurrence in patients and thus improve personalized treatment approaches, make advice and further intensive monitoring.