Justin A. Chen

Mindfulness Training and Stress Reactivity in Substance Abuse: Results from a Randomized, Controlled Stage I Pilot Study

ABSTRACT Stress is important in substance use disorders (SUDs). Mindfulness training (MT) has shown promise for stress-related maladies. No studies have compared MT to empirically validated treatments for SUDs. The goals of this study were to assess MT compared to cognitive behavioral therapy (CBT) in substance use and treatment acceptability, and specificity of MT compared to CBT in targeting stress reactivity. Thirty-six individuals with alcohol and/or cocaine use disorders were randomly assigned to receive group MT or CBT in an outpatient setting. Drug use was assessed weekly. After treatment, responses to personalized stress provocation were measured. Fourteen individuals completed treatment. There were no differences in treatment satisfaction or drug use between groups. The laboratory paradigm suggested reduced psychological and physiological indices of stress during provocation in MT compared to CBT. This pilot study provides evidence of the feasibility of MT in treating SUDs and suggests that MT may be efficacious in targeting stress.

Association between patient beliefs regarding assigned treatment and clinical response: reanalysis of data from the Hypericum Depression Trial Study Group.

OBJECTIVE To reanalyze data from a 2002 study by the Hypericum Depression Trial Study Group to determine whether patients who believed they were receiving active therapy rather than placebo obtained greater improvement, independent of treatment. METHOD Three hundred forty adults with major depressive disorder (according to the Structured Clinical Interview for DSM-IV) and baseline scores of ≥ 20 on the 17-item Hamilton Depression Rating Scale (HDRS-17) were randomized to Hypericum perforatum 900-1,500 mg/d, sertraline 50-100 mg/d, or placebo and were asked to guess their assigned treatment after 8 weeks. This reanalysis of data was performed from October 1, 2009, to April 15, 2011. The intent-to-treat sample included 207 subjects (mean age = 44 years) who had (1) at least 1 postbaseline visit; (2) adherence data based on serum levels of hyperforin, sertraline, and desmethylsertraline; and (3) guess data. Univariate factorial analysis of variance was used to determine whether treatment assignment affected clinical improvement according to HDRS-17 score and whether this effect was moderated by patient guess of sertraline, Hypericum, or placebo. Analysis of covariance was used to determine whether side effects mediated improvement in the context of patient guess and assigned treatment. χ₂ analyses compared response rates (≥ 50% decrease in HDRS-17 score) between the guess groups and between the treatment groups within each guess group. RESULTS Assigned treatment had no significant effect on clinical improvement (P = .65), but patient guess was significantly associated with improvement (P < .001), and treatment and guess interacted significantly (P = .005). Among subjects who guessed placebo, clinical improvement was small and did not differ significantly across treatments. Among subjects who guessed Hypericum, improvement was large and did not differ significantly across treatments. Among subjects who guessed sertraline, those who received placebo or sertraline had large improvements, but those who received Hypericum had significantly less improvement (P < .001). Similar findings were obtained for response rates. CONCLUSIONS Patient beliefs regarding treatment may have a stronger association with clinical outcome than the actual medication received, and the strength of this association may depend upon the particular combination of treatment guessed and treatment received.

Sensitive detection of plasma/serum DNA in patients with systemic lupus erythematosus

Objective: To optimize the use of the fluorochromic PicoGreen assay for the sensitive detection and quantification of double stranded (ds) DNA in plasma/serum samples of patients with systemic lupus erythematosus (SLE). Methods: Plasma/serum samples were obtained from SLE patients and normal healthy donors (NHD). Plasma/serum proteins were digested with proteinase K. DNA was subsequently purified using silica-based ion exchange micro columns and detected using the PicoGreen assay. Results: Sensitive detection of plasma/serum DNA is impaired by proteins: (1) Proteins caused background fluorescence in the PicoGreen assay. (2) Packaging of dsDNA in nucleosomes markedly reduced PicoGreen fluorescence. Therefore, we digested proteins using proteinase K and purified DNA before detection by PicoGreen assay. This procedure resulted in a detection limit for plasma/serum dsDNA of less than 1 ng/ml, and is therefore markedly more sensitive than previously described methods. We found that DNA concentrations are higher in serum than in plasma of healthy donors, suggesting artifactual DNA release during coagulation. In addition, we found higher levels of DNA in plasma and serum of a group of SLE patients compared to NHD. Conclusions: We have optimized the use of the PicoGreen assay for the ultrasensitive and reliable quantification of DNA in plasma/serum samples. This new method can be used in future studies to explore a possible correlation between circulating DNA levels and disease activity in patients with SLE.

Chinese International Students: An Emerging Mental Health Crisis.

Journal of the American Academy of Child & Adolescent Psychiatry - Vol. 54 - N° 11 - p. 879-880

The Effectiveness of Telepsychiatry-Based Culturally Sensitive Collaborative Treatment for Depressed Chinese American Immigrants: A Randomized Controlled Trial.

OBJECTIVE This study evaluates the effectiveness of a telepsychiatry-based culturally sensitive collaborative treatment (T-CSCT) intervention to improve treatment outcomes for depressed Chinese American immigrants. METHODS Participants were Chinese Americans recruited from primary care settings from February 1, 2009, to July 31, 2012, with DSM-IV major depressive disorder (MDD) identified by the Mini-International Neuropsychiatric Interview. Eligible patients were randomized to receive either T-CSCT or treatment as usual (TAU) for 6 months. T-CSCT involves (1) cultural consultation via videoconference and (2) care management. The primary outcome measure was the 17-item Hamilton Depression Rating Scale (HDRS₁₇); positive response was defined as a ≥ 50% decrease in HDRS₁₇ score, and remission was defined as HDRS₁₇ score ≤ 7. Secondary outcome measures were the Clinical Global Impressions-Severity of Illness (CGI-S) and Improvement (CGI-I) scales and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). Outcomes were compared using multivariate logistic regression and mixed-model for repeated measures methods. RESULTS Among participants (N = 190), 63% were female, and the mean (SD) age was 50 (14.5) years. They were randomized to T-CSCT (n = 97; 51%) or TAU (n = 93; 49%). Using multivariate logistic regression analyses, the odds of achieving response and remission were significantly greater for the T-CSCT group compared to the control group (odds ratio [OR] = 3.9 [95% CI, 1.9 to 7.8] and 4.4 [95% CI, 1.9 to 9.9], respectively). Multivariate general linear model analyses showed that patients in the T-CSCT group had significantly greater improvement over time in HDRS₁₇ (F4,95 = 4.59, P = .002), CGI-S (F4,95 = 4.22, P = .003), and CGI-I (F4,95 = 2.95, P = .02) scores. CONCLUSIONS T-CSCT is effective in improving treatment outcomes of Chinese immigrants with MDD. TRIAL REGISTRATION ClincialTrials.gov identifier: NCT00854542.

The Role of Stigma and Denormalization in Suicide-Prevention Laws in East Asia: A Sociocultural, Historical, and Ethical Perspective

Abstract In many Western countries, the criminalization and stigmatization of suicide has given way to a biomedical approach aimed at destigmatizing suicide and treating underlying mental illness. By contrast, in many East Asian countries, suicide has never historically been criminalized or stigmatized. High rates of suicide in Japan, South Korea, and Taiwan have recently led policy makers in those countries to pursue innovative suicide-prevention strategies. The intentional denormalization of harmful behaviors has been discussed in the public health and ethics literatures, particularly with regard to smoking cessation, and could represent a novel mechanism for preventing suicides in East Asia. Using examples from the sociocultural, historical, and legal discourses surrounding suicide in Western and East Asian contexts, we suggest that denormalization can be a justified, culturally relevant suicide-prevention strategy, but that care must be taken to avoid shaming or stigmatizing suicidal individuals. Specifically, we propose the term weak denormalization to refer to an ethically permissible strategy at the mildest end of a spectrum of denormalizing approaches—milder than the reintegrative shaming described in the criminal justice literature, and diametrically opposed to outright stigmatization, which is generally considered ethically impermissible. Given the severe stigma of mental illness in East Asia, adopting the dominant Western view of suicide as solely a psychiatric concern would not be justified. Weak denormalization strategies in East Asia should be culturally tailored and rigorously tested on a small scale. They should include social supports, praise for the bravery of those of who seek help, and strategies to reduce shame regarding perceived social failure.

Racial and Ethnic Diversity in the US Psychiatric Workforce: A Perspective and Recommendations.

Diversity refers to myriad personal characteristics—e.g., race, ethnicity, culture, nationality, religion, language, sexual orientation, gender identity, age, experiences, political party affiliation, and physical abilities, among others. Although a diverse psychiatric workforce would ideally embrace many of these elements, our focus here is on race and ethnicity, since these are two well-studied elements of diversity for physicians. Race and ethnicity are often confused and incorrectly used interchangeably. In general, race is understood to refer to the group a person belongs to based on physical features such as skin color, which reflect ancestry as identified by self or others (e.g., Black, Asian, Hispanic). In contrast, ethnicity refers to the social group a person belongs to, identifies with, or is identified with by others because of shared characteristics such as geographical origins, ancestry, and/or cultural traditions (e.g., Cuban, Pakistani, Taiwanese) [1]. While the US is already home to tremendous racial and ethnic diversity, projections suggest that our nation is on track to become even more diversified [2]. By 2040, non-Hispanic whites will be the minority race in this country, and by 2060, about one in five Americans is projected to be foreign-born [3]. The US healthcare systemwill be challenged to cultivate a more diverse physician workforce to address these changing demographics [4]. This need is even greater in psychiatry, where culture disproportionately impacts key aspects of care including symptom expression and attribution, care-seeking behaviors, stigma, and access to mental health services [5]. We contend that it is necessary for the US mental health care system to increase the training and retention of racial/ ethnic minorities within psychiatry in light of evidence that patients often prefer and report greater satisfaction with racially matched providers, particularly in the field of mental health. Beyond these benefits for direct patient care, increased workplace diversity has been shown to exert positive effects on group performance and innovation, suggesting benefits for provider organizations as well—e.g., through influence at team meetings or other activities [6]. It is implausible to expect that all mental health catchment areas throughout this country will have access to psychiatrists who perfectly reflect all elements of racial and ethnic diversity within the communities they serve, not to mention myriad other characteristics that contribute to personal identity such as gender and sexual orientation. For this reason, in addition to improving the recruitment and retention of minorities into the mental health care workforce, we also believe it is necessary to promote an attitude of cultural respect and humility among all mental health clinicians to prepare them for the challenges of caring for diverse patient populations. We advocate for cultural humility rather than cultural competence because the latter implies a finite outcome with tangible skills, which does not account for the rapidly changing demographics in the US that requires ongoing learning with accumulated skills never reaching a finite end. In this article, we outline demographic trends in the US and their likely impact on healthcare disparities. We then discuss (via clinical vignettes) limitations in the concept of “cultural competence” and argue for the increasingly relevant idea of “cultural respect.” Finally, we provide suggestions on how different stakeholders can contribute to training a more diverse psychiatric workforce while also promoting an attitude of cultural respect among practitioners. * Hermioni N. Lokko hlokko@partners.org

Cross-Cultural Approaches to Mental Health Challenges Among Students

Hillary Clinton described Asian Americans as “among the most prosperous, well-educated, and successful ethnic groups in America.” This seemingly positive stereotype of the “model minority,” frequently promoted by the popular media, may in fact serve to obscure significant challenges faced by this population, particularly with regard to mental health. Issues such as depression and suicidality among Asian American and Asian international students in the United States have become increasingly recognized as major problems at both the high school and university levels, driven by a range of cross-cultural, psychological, familial, and systemic factors. In this chapter, we focus on depression in Asian American and Asian international students as one example of the unique mental health challenges faced by diverse populations in the United States. After outlining the background and context for the chapter, the available literature regarding prevalence of depression in Asian American and Asian international students is summarized. Next, contributing factors and correlates of depression in Asian American and Asian international students are reviewed. Finally, the founding of the MGH Center for Cross-Cultural Student Emotional Wellness is described as one innovative approach to tackling these complex challenges. Clinical recommendations based on the experience of the Center are offered to help foster greater cultural awareness when working with members of these populations.

Transcranial Photobiomodulation for the Treatment of Major Depressive Disorder. The ELATED-2 Pilot Trial

OBJECTIVE Our objective was to test the antidepressant effect of transcranial photobiomodulation (t-PBM) with near-infrared (NIR) light in subjects suffering from major depressive disorder (MDD). BACKGROUND t-PBM with NIR light is a new treatment for MDD. NIR light is absorbed by mitochondria; it boosts cerebral metabolism, promotes neuroplasticity, and modulates endogenous opioids, while decreasing inflammation and oxidative stress. MATERIALS AND METHODS We conducted a double-blind, sham-controlled study on the safety and efficacy (change in Hamilton Depression Rating Scale [HAM-D17] total score at end-point) of adjunct t-PBM NIR [823 nm; continuous wave (CW); 28.7 × 2 cm2; 36.2 mW/cm2; up to 65.2 J/cm2; 20-30 min/session], delivered to dorsolateral prefrontal cortex, bilaterally and simultaneously, twice a week, for 8 weeks, in subjects with MDD. Baseline observation carried forward (BOCF), last observation carried forward (LOCF), and completers analyses were performed. RESULTS The effect size for the antidepressant effect of t-PBM, based on change in HAM-D17 total score at end-point, was 0.90, 0.75, and 1.5 (Cohens d), respectively for BOCF (n = 21), LOCF (n = 19), and completers (n = 13). Further, t-PBM was fairly well tolerated, with no serious adverse events. CONCLUSIONS t-PBM with NIR light demonstrated antidepressant properties with a medium to large effect size in patients with MDD. Replication is warranted, especially in consideration of the small sample size.

Racial/ethnic disparities in US college students’ experience: Discrimination as an impediment to academic performance

ABSTRACT Objective and Participants: Using data from 69,722 US undergraduates participating in the spring 2015 National College Health Assessment, we examine racial/ethnic differences in students’ experience of discrimination. Method: Logistic regression predicted the experience of discrimination and its reported negative effect on academics. Additional models examined the effect of attending a Minority Serving Institution (MSI). Results: Discrimination was experienced by 5–15% of students, with all racial/ethnic minority groups examined- including Black, Hispanic, Asian, AI/NA/NA, and Multiracial students- more likely to report discrimination relative to White students. Of students who experienced discrimination, 15–25% reported it had negatively impacted their academic performance, with Hispanic and Asian students more likely to report negative impacts relative to White students. Attending an MSI was associated with decreased experiences of discrimination. Conclusion: Students from racial/ethnic minority backgrounds are disproportionately affected by discrimination, with negative impacts for academic performance that are particularly marked for Hispanic and Asian students.