Magnitude and sources of distress in mid-life adults with chronic medical illness: an exploratory mixed-methods analysis

Associations between metabolic syndrome and anxiety, and the mediating role of inflammation: Findings from the UK Biobank

OBJECTIVES

To investigate the association between metabolic syndrome (MetS) and anxiety and to explore the mediating role of inflammation indicators in this relationship based on the UK Biobank prospective cohort.

METHODS

This population-based retrospective cohort study analyzed data from 308,352 participants. MetS was defined according to criteria jointly developed by the American Heart Association, the National Heart, Lung, and Blood Institute, and the International Diabetes Federation. Anxiety was defined using ICD-10 codes. Cox proportional risk regression models were used to explore the hazard ratios (HRs) between MetS, components of MetS, number of MetS components, and anxiety. The mediating effect of inflammation on the association between MetS and anxiety was explored using longitudinal mediation analysis.

RESULTS

A total of 308,352 participants were included in this study. Of these, 9471 (3.071 %) developed anxiety over a mean follow-up of 12.05 years. In the fully adjusted model, MetS increased the risk of anxiety by 13.6 % (HR: 1.136, 95 %CI: 1.085-1.189). All MetS components significantly increased the risk of anxiety, with HRs ranging from 1.066 to 1.165. When MetS was treated as a linear variable, the risk of anxiety increased by 6.5 % per component increment. Age-stratified results showed that the risk of MetS for anxiety was higher among those <55 years (HR: 1.23, 95 %CI: 1.13-1.33) than among those ≥55 years (HR: 1.12, 95 %CI: 1.06-1.18). The mediating effects of platelets, lymphocytes, neutrophils, C-reactive protein, leukocytes, and INFLA scores on the association between MetS and anxiety were significant, with mediating effects of 2.30 %, 7.20 %, 15.9 %, 20.7 %, 22.0 %, and 25.3 %, respectively, and a combined mediating effect of these inflammatory factors was 30.8 % (except for INFLA scores).

CONCLUSIONS

MetS and its components significantly increased the risk of anxiety, which increased with the number of components. This association may be partially mediated by serum inflammatory indicators, suggesting that MetS may increase the risk of anxiety by elevating the level of chronic inflammation.

Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors

Suicide is an increasing contributing cause of mortality in middle-aged adults; however, knowledge to guide prevention is limited. This first systematic review and meta-analysis of studies on midlife suicide has provided an overview of published research on this issue and synthesized the evidence on socioeconomic and physical and mental health factors associated with this mortality. Using PRISMA guidelines MEDLINE, Embase, PsycINFO, Scopus and Web of Science were searched for English-language publications that involved persons aged 35 to 65, used individual-level data, and reported prevalence of exposure(s) or relative risks. The search identified 62 studies on midlife suicides and associated factors (28 for SES, 22 for psychiatric disorder and 23 for physical illness). All studies were from high income countries, and most (80.6%) used data from population registries. Meta-analyses showed that the pooled prevalence of exposure in suicide decedents was 57.8% for psychiatric disorder, 56.3% for low income, 43.2% for unemployment, and 27.3% for physical illness. The associated pooled risk ratio was 11.68 (95% confidence intervals: 5.82-23.47) for psychiatric illness of any type, 12.59 (8.29-19.12) for mood disorders, 3.91 (2.72-5.59) for unemployment, 3.18 (2.72-3.72) for being separated or divorced, 2.64 (2.26-3.10) for cancer, 2.50 (0.96-6.38) for central nervous system illness, and 2.26 (1.16-4.41) for low income. In conclusion, midlife suicide is strongly associated with socioeconomic difficulties and physical and psychiatric illnesses that are common in this age population. Future investigations should consider the interactions between risk factors, the intersectionality of sex and ethnicity, and include data from low- and middle-income countries.

A phone and text message intervention to improve physical activity in midlife: initial feasibility testing

Background

Physical activity during midlife (ages 45-64) plays a major role in the prevention of chronic and serious medical conditions. Unfortunately, many midlife adults struggle to be physically active in the setting of low levels of psychological well-being and the management of multiple confluent sources of stress. Effective, scalable, midlife-specific interventions are needed to promote physical activity and prevent the development of chronic medical conditions.

Objectives

In an initial proof-of-concept trial, we assessed the feasibility and acceptability of a new, midlife-adapted, phone- and text message-based intervention using positive psychology (PP) skill-building and motivational interviewing (MI) techniques. We secondarily analyzed post-intervention changes in accelerometer-measured physical activity and self-reported outcomes.

Methods

The PP-MI intervention included six weekly phone sessions with a study trainer, with completion of PP activities and physical activity goals between calls, and in the subsequent six weeks briefer phone check-ins were conducted. Text messages over the 12-week intervention period were utilized to support participants and identify barriers to goal completion. Feasibility (session completion rates) and acceptability (participant ratings of intervention ease and utility) were assessed via descriptive statistics, and pre-post improvements in psychological, functional, and physical activity outcomes at 12 weeks were examined via mixed effects regression models.

Results

Twelve midlife adults with low baseline physical activity enrolled in the single-arm trial. Overall, 76.8% of all possible sessions were completed by participants, and mean ratings of weekly phone sessions were 8.9/10 (SD 1.6), exceeding our a priori thresholds for feasibility and acceptability. Participants demonstrated generally medium to large effect size magnitude improvements in accelerometer-measured physical activity, psychological outcomes, and function.

Conclusions

A novel, midlife-specific phone- and text-based PP-MI intervention was feasible and had promising effects on physical activity and other clinically relevant outcomes, supporting next-step testing of this program via a randomized controlled trial.

The Effects of Urban Green Space on Depressive Symptoms of Mid-Aged and Elderly Urban Residents in China: Evidence from the China Health and Retirement Longitudinal Study

The aim of this study is to assess the impacts of urban green space on depressive symptoms among Chinese urban residents aged 45 and older. In total, 7397 urban respondents were included in this study. Each respondent participated in the China Health and Retirement Longitudinal Study Wave 3 (2015). Environmental-level variables were retrieved from the National Bureau of Statistics database. Both unadjusted and adjusted methods were used in the multilevel regression analysis. Almost one-third of the sample population suffered from depressive symptoms (31.20%). The multilevel logistic regression model showed that green coverage ratio of city-built districts is negatively associated with the prevalence of depressive symptoms among urban mid-aged (OR = 0.79, p < 0.05) and elderly (OR = 0.75, p < 0.05) residents, and the public recreational green space helps to reduce elderly people’s depressive symptoms (OR = 0.77, p < 0.05). This study adds insights about the impact of green space and other environmental factors on depressive symptoms among mid-aged and elderly urban dwellers. It is important to provide enough and accessible overall urban green spaces; additionally, attention should also be paid to specific green space forms such as public recreational green space.

Association of Midlife Status With Response to a Positive Psychology Intervention in Patients With Acute Coronary Syndrome

BACKGROUND

Physical activity is strongly associated with lower risk of recurrent cardiac events in patients who experience an acute coronary syndrome (ACS), yet most patients do not meet recommended levels of physical activity. Psychological well-being is associated with higher levels of physical activity, but midlife adults experience a multitude of stressors that can reduce well-being.

OBJECTIVE

The aim of this study was to compare midlife (age 45-64) and older (age 65+) participants in a positive psychology intervention to increase physical activity and psychological well-being after an ACS.

METHODS

This was a secondary analysis across 3 phases of a telephone-delivered positive psychology intervention development project. Participants were hospitalized for an ACS and had low pre-ACS health behavior adherence. They received 8-12 weekly intervention sessions. Psychological outcomes, self-reported adherence, and physical activity were measured before and after treatment. Mixed regression models were used to compare session completion rates and change in outcome measures between midlife and older participants.

RESULTS

Across 164 participants, midlife participants showed larger improvements in depression, positive affect, and physical activity, but not anxiety or optimism, than older participants; session completion rates did not significantly differ.

CONCLUSIONS

Midlife patients post-ACS may be particularly responsive to a telephone-delivered positive psychology intervention. Clinically, the post-ACS period may be uniquely motivating for midlife patients to improve their physical and psychological health. Future work could customize positive psychology for unique midlife stressors.

Exploring the feasibility and impact of positive psychology-motivational interviewing interventions to promote positive affect and physical activity in type 2 diabetes: design and methods from the BEHOLD-8 and BEHOLD-16 clinical trials

BACKGROUND

Physical activity among those with type 2 diabetes (T2D) is independently associated with superior medical outcomes, but existing behavioral interventions have not led to widespread increases in activity in this population. A remotely delivered intervention that targets well-being constructs associated with greater activity and assists in the creation of specific physical activity goals has the potential to improve activity and outcomes in T2D.

OBJECTIVE

To outline the rationale and methods of two studies designed to assess the impact and optimal duration of a combined positive psychology-motivational interviewing (PP-MI) intervention for inactive persons with T2D.

METHODS

We conducted trials studying 8-week (BEHOLD-8;) and 16-week (BEHOLD-16;) phone-delivered interventions, compared to attention-matched control conditions. In a two-step randomization design, participants were allocated randomly first to study (BEHOLD-8 or BEHOLD-16), then to study condition within study. The primary aims in both trials were feasibility (rates of session completion) and acceptability (participant session ratings), with additional aims examining intervention effects on accelerometer-measured physical activity, psychological measures, and health-related metrics (e.g. vital signs). Main analyses, currently being conducted, will utilize mixed effects models between study conditions, and secondary analyses will utilize the same models to compare the 8- and 16-week PP-MI interventions on feasibility and impact.

RESULTS

Enrollment and data collection have been completed for both trials (BEHOLD-8: N = 60; BEHOLD-16: N = 70), and data analysis is ongoing to assess feasibility and acceptability within study, as well as the relative feasibility and acceptability of the PP-MI interventions across the two studies. We will also explore impact on clinical outcomes between groups.

CONCLUSIONS

This design will address how intervention content (i.e. PP elements vs. no PP elements) and intervention duration (8 weeks vs. 16 weeks) affect feasibility, acceptability, and impact, allowing intervention optimization before a next-step larger clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03150199; NCT03001999.

Melatonin Alleviates Neuroinflammation and Metabolic Disorder in DSS-Induced Depression Rats

There is a bidirectional relationship between inflammatory bowel disease (IBD) and depression/anxiety. Emerging evidences indicate that the liver may be involved in microbiota-gut-brain axis. This experiment focused on the role of melatonin in regulating the gut microbiota and explores its mechanism on dextran sulphate sodium- (DSS-) induced neuroinflammation and liver injury. Long-term DSS-treatment increased lipopolysaccharide (LPS), proinflammation cytokines IL-1β and TNF-α, and gut leak in rats, breaking blood-brain barrier and overactivated astrocytes and microglia. Ultimately, the rats showed depression-like behavior, including reduction of sucrose preference and central time in open field test and elevation of immobility time in a forced swimming test. Oral administration with melatonin alleviated neuroinflammation and depression-like behaviors. However, melatonin supplementation did not decrease the level of LPS but increase short-chain fatty acid (SCFA) production to protect DSS-induced neuroinflammation. Additionally, western blotting analysis suggested that signaling pathways farnesoid X receptor-fibroblast growth factor 15 (FXR-FGF 15) in gut and apoptosis signal-regulating kinase 1 (ASK1) in the liver overactivated in DSS-treated rats, indicating liver metabolic disorder. Supplementation with melatonin markedly inhibited the activation of these two signaling pathways and its downstream p38. As for the gut microbiota, we found that immune response- and SCFA production-related microbiota, like Lactobacillus and Clostridium significantly increased, while bile salt hydrolase activity-related microbiota, like Streptococcus and Enterococcus, significantly decreased after melatonin supplementation. These altered microbiota were consistent with the alleviation of neuroinflammation and metabolic disorder. Taken together, our findings suggest melatonin contributes to reshape gut microbiota and improves inflammatory processes in the hippocampus (HPC) and metabolic disorders in the liver of DSS rats.

A positive psychology-motivational interviewing intervention for patients with type 2 diabetes: Proof-of-concept trial

OBJECTIVE

Eighteen million Americans with type 2 diabetes (T2D) do not follow recommended guidelines for physical activity. Motivational interviewing (MI) has had modest effects on activity and related behaviors in T2D. Positive psychological attributes (e.g., optimism) are associated with superior medical outcomes in T2D, and positive psychology (PP) interventions promote such attributes. There had been no study in T2D of a combined PP-MI intervention to promote well-being and health behavior adherence. We developed a novel, telephone-delivered, 16-week PP-MI intervention and explored its feasibility and impact in T2D patients in a single-arm, proof-of-concept trial.

METHOD

Participants completed PP-based exercises and MI-based physical activity goal-setting activities and reviewed these activities weekly with a study trainer for 16 weeks. Feasibility and acceptability were assessed via exercise completion rates and post-exercise ratings of ease/utility (0-10 scales). Impact was explored by examining changes in physical activity (via accelerometers and self-report), other health behaviors, psychological measures, and medical outcomes (e.g., hemoglobin A1c (A1C)) from baseline to 16 weeks, using paired t tests.

RESULTS

Twelve participants enrolled, and 10 provided follow-up data. Seventy-eight percent of PP-MI activities were completed, and participants rated the PP-MI content and sessions as easy (mean = 8.2/10, standard deviation (SD) = 1.9) and useful (mean = 9.1/10, SD = 1.5). PP-MI was associated with improved adherence to health behaviors and overall self-care, variable effects on accelerometer-measured activity and psychological outcomes, and modest beneficial effects on body mass index and A1C.

CONCLUSION

Further testing of this intervention is warranted in a larger, controlled trial to assess its effects on important health outcomes.

Acceptance and Commitment Therapy Reduces Psychological Stress in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

Patients with Crohn's disease or ulcerative colitis have relatively high levels of stress and psychological dysfunction. Acceptance and commitment therapy (ACT) is a psychological intervention that comprises acceptance and mindfulness procedures, along with commitment and behavior change strategies, to increase psychological flexibility and reduce stress. We performed a randomized controlled trial to investigate the effect of ACT on stress in patients with inflammatory bowel diseases (IBD).

METHODS

A total of 122 patients with quiescent or stable, mildly active IBD were randomly assigned to an 8-week ACT program or treatment as usual (control group). Clinical, demographic, disease activity, and psychological data and blood and feces were collected at baseline and at 8 weeks and 3 months after the intervention (week 20). Scalp hair was collected at baseline and week 20 for measurement of steroid concentrations. The primary endpoint was change in stress symptoms, assessed with the Depression Anxiety Stress Scale. Secondary endpoints included changes in perceived stress, anxiety, depression, quality-of-life domains, disease activity, and cortisol concentration in hair.

RESULTS

Overall, 79 participants were included in the complete case intention-to-treat analysis. There were 39% and 45% reductions in stress in the treatment group from baseline to 8 and 20 weeks, respectively, compared with 8% and 11% in the control group (group × time interaction, P = .001). ACT was associated with reduced perceived stress (P = .036) and depression (P = .010), but not anxiety (P = .388), compared with control individuals. In the intention-to-treat analysis, changes in all 4 quality-of-life domains over time were similar in the ACT and control groups. In the per-protocol analysis, the overall well-being quality-of-life domain improved in the ACT group compared with the control group (P = .009). Subjective and objective disease activity measurements were similar between groups over the study period (all P values >.05). Hair cortisol concentrations correlated with stress (r_s = 0.205, P = .050) and anxiety (r_s = 0.208, P = .046) at baseline but did not change significantly in the ACT group over the study period compared with the control group (P = .831).

CONCLUSION

In a randomized controlled trial of patients with IBD, an 8-week ACT therapy course improved stress and other indices of psychological health.ClinicalTrials.gov Identifier: NCT02350920.