The association between county-level mental health provider shortage areas and suicide rates in the United States during the COVID-19 pandemic

OBJECTIVE

Prior literature has shown that mental health provider Health Professional Shortage Areas (MHPSAs) experienced a greater increase in suicide rates compared to non-shortage areas from 2010 to 2018. Although suicide rates have been on the rise, rates have slightly decreased during the COVID-19 pandemic. This study sought to characterize the differences in suicide rate trends during the pandemic by MHPSA status.

METHOD

We used generalized estimating equation regression to test the associations between MHPSA status and suicide rates from 2018 to 2021. Suicide deaths were obtained from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.

RESULTS

MHPSA status was associated with higher suicide rates (adjusted IRR:1.088 [95% CI, 1.024-1.156]). Furthermore, there was a significant interaction between MHPSA status and year (adjusted IRR:1.056 [95% CI, 1.022-1.091]), such that suicide rates did not significantly change among MHPSAs but slightly decreased among non-MHPSAs from 2018 to 2021.

CONCLUSIONS

During the COVID-19 pandemic, there was a slight decrease in suicide rates among non-MHPSAs, while those with shortages experienced no significant changes in suicide rates. It will be important to closely monitor MHPSAs as continued at-risk regions for suicide as trendlines return to their pre-pandemic patterns.

County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri

Background

Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates.

Methods

In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates).

Results

Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates.

Conclusions

The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.

Developmental perspectives on the origins of psychotic disorders: The need for a transdiagnostic approach

Research on serious mental disorders, particularly psychosis, has revealed highly variable symptom profiles and developmental trajectories prior to illness-onset. As Dante Cicchetti pointed out decades before the term "transdiagnostic" was widely used, the pathways to psychopathology emerge in a system involving equifinality and multifinality. Like most other psychological disorders, psychosis is associated with multiple domains of risk factors, both genetic and environmental, and there are many transdiagnostic developmental pathways that can lead to psychotic syndromes. In this article, we discuss our current understanding of heterogeneity in the etiology of psychosis and its implications for approaches to conceptualizing etiology and research. We highlight the need for examining risk factors at multiple levels and to increase the emphasis on transdiagnostic developmental trajectories as a key variable associated with etiologic subtypes. This will be increasingly feasible now that large, longitudinal datasets are becoming available and researchers have access to more sophisticated analytic tools, such as machine learning, which can identify more homogenous subtypes with the ultimate goal of enhancing options for treatment and preventive intervention.

The association between neighborhood-level social fragmentation and distressing psychotic-like experiences in early adolescence: the moderating role of close friends

BACKGROUND

Early exposure to neighborhood social fragmentation has been shown to be associated with schizophrenia. The impact of social fragmentation and friendships on distressing psychotic-like experiences (PLE) remains unknown. We investigate the relationships between neighborhood social fragmentation, number of friends, and distressing PLE among early adolescents.

METHODS

Data were collected from the Adolescent Brain Cognitive Development Study. Generalized linear mixed models tested associations between social fragmentation and distressing PLE, as well as the moderating role of the number of total and close friends.

RESULTS

Participants included 11 133 adolescents aged 9 to 10, with 52.3% being males. Greater neighborhood social fragmentation was associated with higher levels of distressing PLE (adjusted β = 0.05; 95% CI: 0.01-0.09). The number of close but not total friends significantly interacted with social fragmentation to predict distressing PLE (adjusted β = -0.02; 95% CI: -0.04 to <-0.01). Among those with fewer close friends, the association between neighborhood social fragmentation and distressing PLE was significant (adjusted β = 0.07; 95% CI: 0.03-0.11). However, among those with more close friends, the association was non-significant (adjusted β = 0.03; 95% CI: -0.01 to 0.07).

CONCLUSIONS

Greater neighborhood social fragmentation is associated with higher levels of distressing PLE, particularly among those with fewer close friends. Further research is needed to disentangle aspects of the interaction between neighborhood characteristics and the quality of social interactions that may contribute to psychosis, which would have implications for developing effective interventions at the individual and community levels.

Social connections as determinants of cognitive health and as targets for social interventions in persons with or at risk of Alzheimer's disease and related disorders: a scoping review

BACKGROUND

Social connections have a significant impact on health across age groups, including older adults. Loneliness and social isolation are known risk factors for Alzheimer's disease and related dementias (ADRD). Yet, we did not find a review focused on meta-analyses and systematic reviews of studies that had examined associations of social connections with cognitive decline and trials of technology-based and other social interventions to enhance social connections in people with ADRD.

STUDY DESIGN

We conducted a scoping review of 11 meta-analyses and systematic reviews of social connections as possible determinants of cognitive decline in older adults with or at risk of developing ADRD. We also examined eight systematic reviews of technology-based and other social interventions in persons with ADRD.

STUDY RESULTS

The strongest evidence for an association of social connections with lower risk of cognitive decline was related to social engagement and social activities. There was also evidence linking social network size to cognitive function or cognitive decline, but it was not consistently significant. A number of, though not all, studies reported a significant association of marital status with risk of ADRD. Surprisingly, evidence showing that social support reduces the risk of ADRD was weak. To varying degrees, technology-based and other social interventions designed to reduce loneliness in people with ADRD improved social connections and activities as well as quality of life but had no significant impact on cognition. We discuss strengths and limitations of the studies included.

CONCLUSIONS

Social engagement and social activities seem to be the most consistent components of social connections for improving cognitive health among individuals with or at risk for ADRD. Socially focused technology-based and other social interventions aid in improving social activities and connections and deserve more research.

Relations of Lifetime Perceived Stress and Basal Cortisol With Hippocampal Volume Among Healthy Adolescents and Those at Clinical High Risk for Psychosis: A Structural Equation Modeling Approach

BACKGROUND

Hippocampal volume (HV) is sensitive to environmental influences. Under normative conditions in humans, HV increases linearly into childhood and asymptotes in early adulthood. Studies of humans and nonhuman animals have provided evidence of inverse relationships between several measures of stress and HV.

METHODS

Using structural equation modeling, this study aimed to characterize the relationships of age, basal cortisol, biological sex, and lifetime perceived stress with bilateral HV in a sample of healthy adolescents and adolescents at clinical high risk for psychosis (CHR-P) (N = 571, 43% female; age range = 12-19.9 years). This sample included 469 individuals at CHR-P and 102 healthy comparison participants from the combined baseline cohorts of the second and third NAPLS (North American Prodrome Longitudinal Study).

RESULTS

A structural model that constrained the individual effects of basal cortisol and perceived stress to single path coefficients, and freely estimated the effects of age and biological sex in group models, optimized model fit and parsimony relative to other candidate models. Significant inverse relationships between basal cortisol and bilateral HV were observed in adolescents at CHR-P and healthy comparison participants. Significant sex differences in bilateral HV were also observed, with females demonstrating smaller HV than males in both groups.

CONCLUSIONS

Multigroup structural equation modeling revealed heterogeneity in the relationships of age and biological sex with basal cortisol, lifetime perceived stress, and bilateral HV in individuals at CHR-P and healthy comparison participants. Moreover, the findings support previous literature indicating that elevated basal cortisol is a nonspecific risk factor for reduced HV.

Association of Childhood Area-Level Ethnic Density and Psychosis Risk Among Ethnoracial Minoritized Individuals in the US

Importance

The protective ethnic density effect hypothesis, which suggests that minoritized individuals who grow up in neighborhoods with a high proportion of ethnoracial minoritized groups are protected from the effects of perceived discrimination, has not been examined among individuals at clinical high risk of psychosis (CHR-P). This level of examination may help identify intervention targets for preventing psychosis among high-risk individuals.

Objective

To examine the association between area-level ethnic density during childhood, perceived discrimination, and psychosis risk outcomes among ethnoracial minoritized individuals with CHR-P.

Design, Setting, and Participants

Data were collected as part of the North American Prodrome Longitudinal Study-2 (NAPLS 2) between November 2008 and March 2013. Participants included ethnoracial minoritized youth with CHR-P. Area-level ethnoracial minoritized density pertained to the percent of ethnoracial minoritized individuals within the participant's county during childhood. Generalized mixed-effects models with random intercepts for participants, NAPLS 2 site, and county estimated the associations between area-level ethnic density and the risk of psychosis risk outcomes. Self-reported experience of discrimination was assessed. Mediation analyses computed the indirect association of perceived discrimination in the prospective correlation between ethnic density and psychosis risk outcomes. Analyses took place between December 2021 and June 2023.

Main Outcomes and Measures

Psychosis risk outcomes included remission, symptomatic, progression, and conversion to psychosis and were assessed throughout 24-month follow-up.

Results

Of 193 individuals, the mean (SD) age was 17.5 (3.4) years and 113 males (58.5%) were included. Participants self-identified as Asian (29 [15.0%]), Black (57 [29.0%]), Hispanic (any race; 87 [45.0%]), or other (First Nations, Middle Eastern, and interracial individuals; 20 [10.4%]). Greater area-level minoritized density was associated with a lower likelihood of remaining symptomatic (relative risk [RR], 0.54 [95% CI, 0.33-0.89]) and having progressively worsening symptoms (RR, 0.52 [95% CI, 0.32-0.86]) compared with being in remission. More perceived discrimination was associated with a higher risk of staying symptomatic (RR, 1.43 [95% CI, 1.09-1.88]) and progressively worsening (RR, 1.34 [95% CI, 1.02-1.78]) compared with being in remission. Perceived discrimination significantly mediated 21.7% (95% CI, 4.1%-67.0%; P = .02) of the association between area-level minoritized density and the likelihood of being in remission.

Conclusions and Relevance

This study found that among ethnoracial minority youth with CHR-P, growing up in communities with a greater proportion of ethnically minoritized individuals was associated with remission of psychosis risk symptoms partly through lower levels of perceived discrimination. Understanding how the social environment impacts early psychosis risk may help develop effective interventions to prevent psychosis, especially for vulnerable minoritized youth.

Associations Between Childhood Area-Level Social Fragmentation, Maladaptation to School, and Social Functioning Among Healthy Youth and Those at Clinical High Risk for Psychosis

BACKGROUND AND HYPOTHESIS

Although studies have identified social fragmentation as an important risk factor for schizophrenia and other psychotic disorders, it is unknown whether it may impact social functioning. This study investigates whether social fragmentation during childhood predicts maladaptation to school as well as social functioning during childhood and adulthood.

STUDY DESIGN

Data were collected from the North American Prodrome Longitudinal Study. Participants included adults at clinical high risk for psychosis (CHR-P) and healthy comparisons (HC). Maladaptation to school and social functioning during childhood were assessed retrospectively and social functioning in adulthood was assessed at baseline.

STUDY RESULTS

Greater social fragmentation during childhood was associated with greater maladaptation to school (adjusted β = 0.21; 95% CI: 0.02 to 0.40). Social fragmentation was not associated with social functioning during childhood (unadjusted β = -0.08; 95% CI: -0.31 to 0.15). However, greater social fragmentation during childhood predicted poorer social functioning in adulthood (adjusted β = -0.43; 95% CI: -0.79 to -0.07). Maladaptation to school mediated 15.7% of the association between social fragmentation and social functioning. The association between social fragmentation and social functioning was stronger among adults at CHR-P compared to HC (adjusted β = -0.42; 95% CI: -0.82 to -0.02).

CONCLUSIONS

This study finds that social fragmentation during childhood is associated with greater maladaptation to school during childhood, which in turn predicts poorer social functioning in adulthood. Further research is needed to disentangle aspects of social fragmentation that may contribute to social deficits, which would have implications for the development of effective interventions at the individual and community levels.

Associations between childhood ethnoracial minority density, cortical thickness, and social engagement among minority youth at clinical high-risk for psychosis

An ethnoracial minority density (EMD) effect in studies of psychotic spectrum disorders has been observed, whereby the risk of psychosis in ethnoracial minority group individuals is inversely related to the proportion of minorities in their area of residence. The authors investigated the relationships among area-level EMD during childhood, cortical thickness (CT), and social engagement (SE) in clinical high risk for psychosis (CHR-P) youth. Data were collected as part of the North American Prodrome Longitudinal Study. Participants included 244 ethnoracial minoritized (predominantly Hispanic, Asian and Black) CHR-P youth and ethnoracial minoritized healthy controls. Among youth at CHR-P (n = 164), lower levels of EMD during childhood were associated with reduced CT in the right fusiform gyrus (adjusted β = 0.54; 95% CI 0.17 to 0.91) and right insula (adjusted β = 0.40; 95% CI 0.05 to 0.74). The associations between EMD and CT were significantly moderated by SE: among youth with lower SE (SE at or below the median, n = 122), lower levels of EMD were significantly associated with reduced right fusiform gyrus CT (adjusted β = 0.72; 95% CI 0.29 to 1.14) and reduced right insula CT (adjusted β = 0.57; 95% CI 0.18 to 0.97). However, among those with greater SE (n = 42), the associations between EMD and right insula and fusiform gyrus CT were not significant. We found evidence that lower levels of ethnic density during childhood were associated with reduced cortical thickness in regional brain regions, but this association may be buffered by greater levels of social engagement.

Lexical Diversity and Other Linguistic Measures in Schizophrenia: Associations With Negative Symptoms and Neurocognitive Performance

ABSTRACT

Straightforward linguistic measures may be indicators of reduced language production and lexical diversity among individuals with schizophrenia with negative symptoms and neurocognitive impairments. We compared 98 patients with schizophrenia to 101 unaffected controls on six language variables ( e.g. , number of relationships between objects, use of complex transitions in the narrative structure), number of words produced, and lexical diversity computed as the moving average type-token ratio from both speaking and writing tasks. Patients differed from controls on nearly all of the linguistic measures; number of words produced had the strongest effect, with an average Cohen's d of 0.68; values pertaining to lexical diversity were 0.50 and 0.32, respectively, for the speaking tasks and the writing tasks. Most measures were correlated with alogia and other domains of negative symptoms (including avolition-apathy and anhedonia-asociality), as well as with diverse neurocognitive domains, especially those pertaining to working memory, verbal learning, and verbal category fluency. Further work is needed to understand longitudinal changes in these linguistic variables, as well as their utility as measures of alogia.

Prevalence of Food Insecurity and Living in a Food Desert among Individuals with Serious Mental Illnesses in Public Mental Health Clinics

Very little is known about the prevalence of food insecurity-and living in a food desert-among persons with serious mental illnesses, such as schizophrenia and major mood disorders. This study evaluated those prevalences and assessed for associations with six other variables. Surveys were conducted with 300 patients with a psychotic or mood disorder receiving outpatient services at five community mental health agencies in Washington, D.C. The prevalences of low food security and very low food security were 68.9% and 46.8%, compared to national rates of 13.7% (13.2% in Washington, D.C.) and 5.4% (4.8% in Washington, D.C.). 50.0% of participants lived in food desert census tracts, which was associated with both severe and morbid obesity (p = .02 and p = .03, respectively). Additional research, evaluation of clinical implications, and potential policy approaches to these concerning social determinants of physical and mental health, in an already vulnerable patient population, are warranted.

Residential instability during adolescence predicts earlier age at onset of psychosis: The moderating role of extraversion

INTRODUCTION

Residential instability (RI) during adolescence is associated with poor health outcomes. Also, extraversion has been shown to be a moderator of these associations. However, the associations between RI, extraversion, and age at onset of psychosis (AOP) remain unknown.

METHODS

Data were collected from patients with first-episode psychosis (FEP). Linear regression models assessed the association between RI during adolescence and AOP. Extraversion was tested as a moderator using the interaction term RI-by-extraversion.

RESULTS

Among 89 participants with FEP, both RI (adjusted β = -.278, p = .006) and the interaction term RI-by-extraversion (adjusted β = .290, p < .001) were associated with earlier AOP. Stratified analyses showed that RI was only significantly associated with earlier AOP among those with low extraversion (adjusted β = -.598, p < .001).

CONCLUSIONS

RI predicted earlier AOP and this association was moderated by extraversion. These findings suggest that extraversion may buffer the negative relationship between RI and AOP. Future research should replicate these findings.

The Association Between Neighborhood Poverty and Hippocampal Volume Among Individuals at Clinical High-Risk for Psychosis: The Moderating Role of Social Engagement

Reductions in hippocampal volume (HV) have been associated with both prolonged exposure to stress and psychotic illness. This study sought to determine whether higher levels of neighborhood poverty would be associated with reduced HV among individuals at clinical high-risk for psychosis (CHR-P), and whether social engagement would moderate this association. This cross-sectional study included a sample of participants (N  =  174, age-range = 12-33 years, 35.1% female) recruited for the second phase of the North American Prodrome Longitudinal Study. Generalized linear mixed models tested the association between neighborhood poverty and bilateral HV, as well as the moderating role of social engagement on this association. Higher levels of neighborhood poverty were associated with reduced left (β  =  -0.180, P  =  .016) and right HV (β  =  -0.185, P  =  .016). Social engagement significantly moderated the relation between neighborhood poverty and bilateral HV. In participants with lower levels of social engagement (n  =  77), neighborhood poverty was associated with reduced left (β  =  -0.266, P  =  .006) and right HV (β = -0.316, P  = .002). Among participants with higher levels of social engagement (n = 97), neighborhood poverty was not significantly associated with left (β  =  -0.010, P  =  .932) or right HV (β  =  0.087, P  =  .473). In this study, social engagement moderated the inverse relation between neighborhood poverty and HV. These findings demonstrate the importance of including broader environmental influences and indices of social engagement when conceptualizing adversity and potential interventions for individuals at CHR-P.

The associations between area-level residential instability and gray matter volumes from the North American Prodrome Longitudinal Study (NAPLS) consortium

INTRODUCTION

Area-level residential instability (ARI), an index of social fragmentation, has been shown to explain the association between urbanicity and psychosis. Urban upbringing has been shown to be associated with reduced gray matter volumes (GMV)s of brain regions corresponding to the right caudal middle frontal gyrus (CMFG) and rostral anterior cingulate cortex (rACC). We hypothesize that greater ARI will be associated with reduced right CMFG and rACC GMVs.

METHODS

Data were collected at baseline as part of the North American Prodrome Longitudinal Study Phase 2. Counties where participants resided during childhood were geographically coded using the US Census to area-level factors. ARI was defined as the percentage of residents living in a different house 5 years ago. Generalized linear mixed models tested associations between ARI and GMVs.

RESULTS

This study included 29 healthy controls (HC)s and 64 clinical high risk for psychosis (CHR-P) individuals who were aged 12 to 24 years, had remained in their baseline residential area, and had magnetic resonance imaging scans. ARI was associated with reduced right CMFG (adjusted β = -0.258; 95% CI = -0.502 to -0.015) and right rACC volumes (adjusted β = -0.318; 95% CI = -0.612 to -0.023). The interaction term (ARI-by-diagnostic group) in the prediction of both brain regions was not significant, indicating that the relationships between ARI and regional brain volumes held for both CHR-P and HCs.

CONCLUSIONS

ARI may adversely impact similar brain regions as urban upbringing. Further investigation into the potential mechanisms of the relationship between ARI and neurobiology, including social stress, is needed.

Social Fragmentation and Schizophrenia: A Systematic Review

Objective: Accumulating evidence implicates social context in the etiology of psychosis. One important line of epidemiologic research pointing to a potentially causal role of social context pertains to what is termed social fragmentation. The authors conducted a systematic review of the relationship between area-level social fragmentation and psychosis. Data Sources: Three databases (MEDLINE, PsycINFO, and Web of Science) were searched from inception to May 2, 2021. There were no language restrictions. Search terms were those that identify the area-level orientation, social fragmentation, sample, and outcome. Study Selection: Inclusion criteria were the following: (1) social environment measured at the area level with (2) psychosis outcomes (incidence rates, prevalence of psychosis or schizophrenia, age at onset of psychosis, psychotic symptom severity, and duration of untreated psychosis). In total, 579 research articles were identified, and 19 were eligible to be included in this systematic review. Data Extraction: Two reviewers independently screened, extracted data from, and coded all articles. Results: Evidence from 14 of 19 articles indicates that area-level characteristics reflecting social fragmentation are associated with higher psychosis rates and other outcomes of psychosis even after controlling for other area-level characteristics including deprivation, social capital, race/ethnicity, and urbanicity and individual-level characteristics including age, sex, migrant status, and socioeconomic status. Conclusions: In conclusion, this review finds evidence that measures of area-level social fragmentation are associated with higher psychosis rates. Further research into mechanisms is needed to better characterize this association.

Association between residential instability at individual and area levels and future psychosis in adolescents at clinical high risk from the North American Prodrome Longitudinal Study (NAPLS) consortium

OBJECTIVE

Accumulating evidence supports an association between residential instability and increased risk for psychosis, but the association between residential instability and conversion to psychosis among adolescents at clinical high risk (CHR) is unclear. In this study, we determined whether individual-level and area-level residential instability and their interaction are associated with conversion to psychosis within two years.

METHODS

Data were collected as part of the North American Prodrome Longitudinal Study Phase 2. Individual-level residential instability, defined as having ever moved during lifetime, was derived from the Life Events Scale. Area-level residential instability, defined as the percentage of people who were not living in the same house five years ago, was derived from the U.S. Decennial Censuses.

RESULTS

This study included 285 adolescents at CHR (including 36 subjects who later converted to full psychosis). We found that individual-level residential instability was associated with conversion (adjusted OR = 2.769; 95% CI = 1.037-7.393). The interaction between individual-level and area-level residential instability was significant (p = 0.030). In a subgroup of CHR participants who have never moved (n = 91), area-level residential instability during childhood was associated with conversion (adjusted OR = 1.231; 95% CI = 1.029-1.473). Conversely, in a subgroup of CHR participants who resided in residentially stable areas during childhood (n = 142), the association between individual-level residential instability and conversion remained significant (adjusted OR = 15.171; 95% CI = 1.753-131.305).

CONCLUSIONS

These findings suggest that individual-level and area-level residential instability may be associated with conversion to psychosis.

Computational linguistic analysis applied to a semantic fluency task: A replication among first-episode psychosis patients with and without derailment and tangentiality

Automated tools do not yet exist to measure formal thought disorder, including derailment and tangentiality, both of which can be subjectively rated using the Scale for the Assessment of Positive Symptoms after a clinical research interview. CoVec, a new automated tool, measures the semantic similarity among words averaged in a five- and ten-word window (Coherence-5 and Coherence-10, respectively). One prior report demonstrated that this tool was able to differentiate between patients with those types of thought disorder and patients without them (and controls). Here, we attempted a replication of the initial findings using data from a different sample of patients hospitalized for initial evaluation of first-episode psychosis. Participants were administered a semantic fluency task and the animal lists were analyzed with CoVec. In this study, we partially replicated the prior findings, showing that first-episode patients with derailment had significantly lower Coherence-5 and Coherence-10 compared with patients without derailment. Further research is warranted on this and other highly reliable and objective methods of detecting formal thought disorder through simple assessments such as semantic fluency tasks.

Associations between mental health shortage areas and county-level suicide rates among adults aged 25 and older in the USA, 2010 to 2018

OBJECTIVE

Suicide is a serious public health concern, but little is known about the relationship between access to mental health care and suicide deaths, and whether suicide rates differ by mental health provider Health Professional Shortage Areas (HPSAs). This study investigated the associations between mental health HPSAs and suicide rates.

METHOD

We used generalized linear mixed models to test the associations between HPSAs and suicide rates from 2010 to 2018. For each county during a 3-year period, the total number of suicides was obtained from Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER).

RESULTS

Mental health HPSAs had higher suicide rates (adjusted incidence rate ratio (IRR), 1.06 [95% CI, 1.03-1.09]). The interaction terms of mental health HPSAs and time (adjusted IRR, 1.01 [95% CI, 1.00-1.01]) showed that the association between mental health shortage areas and suicide rates has increased over time.

CONCLUSIONS

Suicide rates are more common in mental health provider shortage areas, and this association has been growing over time. The study's findings suggest that many communities in the US are likely facing simultaneous challenges of limited access to mental health care, social and economic disadvantage, and high burden of suicide.

Transcutaneous vagal nerve stimulation blocks stress-induced activation of Interleukin-6 and interferon-γ in posttraumatic stress disorder: A double-blind, randomized, sham-controlled trial

Posttraumatic stress disorder (PTSD) is a highly disabling condition associated with alterations in multiple neurobiological systems, including increases in inflammatory function. Vagus nerve stimulation (VNS) decreases inflammation, however few studies have examined the effects of non-invasive VNS on physiology in human subjects, and no studies in patients with PTSD. The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on inflammatory responses to stress. Thirty subjects with a history of exposure to traumatic stress with (N ​= ​10) and without (N ​= ​20) PTSD underwent exposure to stressful tasks immediately followed by active or sham tcVNS and measurement of multiple biomarkers of inflammation (interleukin-(IL)-6, IL-2, IL-1β, Tumor Necrosis Factor alpha (TNFα) and Interferon gamma (IFNγ) over multiple time points. Stressful tasks included exposure to personalized scripts of traumatic events on day 1, and public speech and mental arithmetic (Mental Stress) tasks on days 2 and 3. Traumatic scripts were associated with a pattern of subjective anger measured with Visual Analogue Scales and increased IL-6 and IFNγ in PTSD patients that was blocked by tcVNS (p ​< ​.05). Traumatic stress had minimal effects on these biomarkers in non-PTSD subjects and there was no difference between tcVNS or sham. No significant differences were seen between groups in IL-2, IL-1β, or TNFα. These results demonstrate that tcVNS blocks behavioral and inflammatory responses to stress reminders in PTSD.

Neighborhood Predictors of Outpatient Mental Health Visits Among Persons With Comorbid Medical and Serious Mental Illnesses

OBJECTIVE

Individuals with serious mental illnesses are at risk of receiving inadequate outpatient mental health services, increasing the likelihood of medication nonadherence, readmission, and self-harm. The purpose of this study was to identify individual- and neighborhood-level factors associated with outpatient mental health visits.

METHODS

This study included 418 participants from two randomized trials of patients with comorbid medical conditions and serious mental illnesses across two study sites between 2011 and 2017. On the basis of individual addresses, data were collected about participants' distance to the nearest mental health facility and 13 neighborhood characteristics from the American Community Survey. Three neighborhood-level factors were derived from factor analysis. Poisson regression was used to assess associations between individual- and neighborhood-level characteristics and the number of visits to mental health providers. Known individual-level risk factors for outpatient follow-up were mutually adjusted in a model with neighborhood covariates added.

RESULTS

Male gender, older age, unemployment, and lower education level were associated with less outpatient mental health service utilization. Neighborhood-level residential mobility, defined as the combination of percentage of residents living in a different house in the past year and percentage of non-owner-occupied housing, was significantly associated with fewer mental health service visits even after controlling for other neighborhood- and individual-level factors.

CONCLUSIONS

Among individuals with comorbid medical conditions and serious mental illnesses, living in neighborhoods with higher residential mobility was associated with fewer visits to outpatient mental health providers. This finding suggests the importance of recognizing social conditions that may shape clinical interactions.

Neighborhood-level predictors of age at onset and duration of untreated psychosis in first-episode psychotic disorders

OBJECTIVE

Recent years have witnessed growing interest in the role of the social environment in the development and outcomes of schizophrenia. We investigated whether neighborhood characteristics are associated with two important prognostic factors in early-course psychosis, age at onset of psychosis (AOP) and duration of untreated psychosis (DUP).

METHODS

Data were collected from patients admitted to the hospital for first-episode schizophrenia-spectrum disorder. We collected data on perceived neighborhood disorder during childhood/adolescence and extracted data on 13 neighborhood characteristics from the American Community Survey based upon individual addresses. Four neighborhood-level factors were derived from factor analysis. Multiple logistic regression analyses assessed the association between specific neighborhood characteristics and the two prognostic factors (earlier AOP and longer DUP) in early-course psychosis.

RESULTS

143 participants had valid addresses geo-coded. Neighborhood-level residential instability was associated with an earlier AOP (OR = 1.760; p = 0.022) even after controlling for known risk factors (OR = 2.026; p = 0.020) and also after controlling for individual-level residential instability (OR = 1.917; p = 0.037). The general socioeconomic status neighborhood factor (OR = 1.119; p = 0.019) and perceived neighborhood disorder (OR = 1.075; p = 0.005) were associated with a longer DUP. But only perceived neighborhood disorder (OR = 1.146; p = 0.011) remained significant, and general socioeconomic status was close to significant (OR = 1.215; p = 0.062), after controlling for individual-level predictors and socioeconomic status.

CONCLUSIONS

This study found evidence that neighborhood-level characteristics (in this case, residential instability) may be associated with earlier AOP, and perceptions of neighborhood disorder are associated with a longer treatment delay. Socioenvironmental factors should be more consistently considered going forward in research on early psychotic disorders.

Computational linguistic analysis applied to a semantic fluency task to measure derailment and tangentiality in schizophrenia

Although rating scales to assess formal thought disorder exist, there are no objective, high-reliability instruments that can quantify and track it. This proof-of-concept study shows that CoVec, a new automated tool, is able to differentiate between controls and patients with schizophrenia with derailment and tangentiality. According to ratings from the derailment and tangentiality items of the Scale for the Assessment of Positive Symptoms, we divided the sample into three groups: controls, patients without formal thought disorder, and patients with derailment/tangentiality. Their lists of animals produced during a one-minute semantic fluency task were processed using CoVec, a newly developed software that measures the semantic similarity of words based on vector semantic analysis. CoVec outputs were Mean Similarity, Coherence, Coherence-5, and Coherence-10. Patients with schizophrenia produced fewer words than controls. Patients with derailment had a significantly lower mean number of words and lower Coherence-5 than controls and patients without derailment. Patients with tangentiality had significantly lower Coherence-5 and Coherence-10 than controls and patients without tangentiality. Despite the small samples of patients with clinically apparent thought disorder, CoVec was able to detect subtle differences between controls and patients with either or both of the two forms of disorganization.

Injury in aged animals robustly activates quiescent olfactory neural stem cells

While the capacity of the olfactory epithelium (OE) to generate sensory neurons continues into middle age in mice, it is presumed that this regenerative potential is present throughout all developmental stages. However, little experimental evidence exists to support the idea that this regenerative capacity remains in late adulthood, and questions about the functionality of neurons born at these late stages remain unanswered. Here, we extend our previous work in the VNO to investigate basal rates of proliferation in the OE, as well as after olfactory bulbectomy (OBX), a commonly used surgical lesion. In addition, we show that the neural stem cell retains its capacity to generate mature olfactory sensory neurons in aged animals. Finally, we demonstrate that regardless of age, a stem cell in the OE, the horizontal basal cell (HBC), exhibits a morphological switch from a flattened, quiescent phenotype to a pyramidal, proliferative phenotype following chemical lesion in aged animals. These findings provide new insights into determining whether an HBC is active or quiescent based on a structural feature as opposed to a biochemical one. More importantly, it suggests that neural stem cells in aged mice are responsive to the same signals triggering proliferation as those observed in young mice.

Effect of Pain Medication Choice on Emergency Room Visits for Pain after Ambulatory Laparoscopic Cholecystectomy

Inadequate pain control after ambulatory surgery can lead to unexpected return visits to the hospital. The purpose of this study was to compare patients based on which medications they were prescribed and to see whether this affected the rate of return to the hospital. A retrospective chart review of patients who underwent ambulatory laparoscopic cholecystectomy between January 2009 and December 2013 was performed. Patients were divided into two groups based on the pain medication prescribed after surgery: Opioids and nonopioids. Patients returning to the Emergency room (ER) within seven days were evaluated. If no complication or other diagnosis was identified, the patient was considered to have returned for inadequate pain control. The two groups were statistically compared with each other using Fisher's exact chi-squared test. A total of 749 patients underwent laparoscopic cholecystectomy during the study period: 180 (25.2%) were prescribed opioids, whereas, 560 (74.8%) were prescribed nonopioids. In the nonopioid group, 14 (1.9%) returned to the ER for pain, whereas no patient in the opioid group returned for pain. This difference was statistically significant (P = 0.027). In conclusion, patients who were given opioid pain medications after ambulatory laparoscopic cholecystectomy were less likely to return to the ER for pain. This implied that opioids were better at pain control and helped avoid the costs of unnecessary ER visits. Future research should be aimed at more direct measures of pain control, as well as the role of opioids after inpatient surgery.

Fangchinoline inhibited the antinociceptive effect of morphine in mice

Fangchinoline (FAN), a non-specific calcium antagonist, is a major alkaloidal component of the creeper Stephania tetrandra S. Moore (or fenfangji). It has been shown to possess antagonistic activity on morphine-induced antinociception in mice. This study was undertaken to assess the antagonistic mechanism. The results demonstrated that FAN (IP) attenuated morphine (SC)-induced antinociception in a dose-dependent manner with significant effect at doses of 30 and 60mg/kg body wt. (IP) in the tail-flick test but not the tail-pinch tests, carried out in mice. This antagonism was abolished by pretreatment with a serotonin precursor, 5-hydroxytryptophan (5-HTP, IP), but not by pretreatment with a noradrenaline precursor, L-dihydroxyphenylalanine (L-DOPA, IP) in the tail-flick test. On the other hand, the development of morphine-induced analgesic tolerance was not prevented by FAN. These results suggest that the serotonergic pathway may be involved in the antagonism of morphine-induced antinociception by FAN and, in agreement with other reports, also indicates the possible dissociation of the morphine analgesic effect from its tolerance-development mechanism.

Detection of epidermal growth factor receptor in the serum of patients with cervical carcinoma

Epidermal growth factor receptor (EGFR) is overexpressed in a variety of malignancies, including breast, lung, gastric, and cervical carcinoma. Its overexpression has been associated with disease progression or poor prognosis in patients with cervical carcinoma. In the present study, the levels of EGFR were determined in serum from 38 patients with cervical carcinoma [invasive or recurrent carcinoma (n = 26) and carcinoma in situ (CIS; n = 12)] and 38 healthy female controls using ELISA. The mean serum level for EGFR in patients with invasive or recurrent carcinoma (165 +/- 60 fmol/ml) was significantly elevated (P < 0.0001) compared with that of healthy controls (66 +/- 17 fmol/ml) and also higher (P = 0.015) than that of patients with CIS (126 +/- 25 fmol/ml). In addition, there was a significant difference in the mean serum levels of EGFR between patients with CIS and healthy controls (P < 0.0001). Thirty-five patients (92%) with cervical carcinoma [invasive or recurrent (n = 24) and CIS (n = 11)] had elevated serum, EGFR levels above the cutoff value of 100 fmol/ml (defined as 2 SD above the mean of the controls). In conclusion, the serum EGFR level was elevated in a significant proportion of patients with cervical carcinoma, and it demonstrated an increasing tendency according to disease progression from normal tissue through CIS to invasive cervical carcinoma. Therefore, it may have a potential usefulness as a biological marker of cervical carcinoma.

[Regulation of SWS by hormones and cytokines]

SWS is the most important component of sleep. (1) VLPO-TMN seems to generate sleep and wakefulness. The rostral basal forebrain, which was defined as PGD2-SPZ, may be involved in regulation of sleep. (2) PGD2 promotes sleep, especially SWS, while PGE2 prolongs wakefulness and depresses both SWS and REMS. (3) During SWS the activation of hypothalamus-pituitary-adrenocortic axis is inhibited, while the release of growth hormone is accelerated. The soporific effects of melatonin may be attributed to its hypothermic effects. (4) Interleukin-1 prolongs sleep, especially SWS, which seems to be mediated by PGD2. Tumor necrosis factor (TFN) may promote SWS through 5-HT and its receptor. Therefore, the development of new hypnotics, which selectively prolong SWS, might follow the following ways: PGD2 and chemicals which act like PGD2; immuno-regulators; substances with effects on 5-HT receptors; hormone, such as melatonin and growth hormone, which play roles in the physiological regulation on sleep-wakefulness.

[Stimulative effect of electro-blunt-tip needle on the points of human skin and its analgesia in rats]

The stimulative effect of electro-blunt-tip needle (a kind of electroacupuncture stimulating on the surface of skin point) on the 120 points of human skin was observed in 12 healthy volunteers. It was shown that the substitute typical electro-blunt-tip needle stimulator and its special pen-like electrode by a general electroacupuncture stimulator and a tape-like adjustable electrode and similar therapeutic effects. It was found in animal experiment that the pain threshold determined with rat tail flick analgesia method was raised by electroacupuncture and electro-blunt-tip needle, the optimal stimulating time being 10-20 minutes for both, the percentages of the maximal changing pain threshold being 206.6% and 175.4%, and the corresponding voltage being 2v and 7v respectively.

Effects of catecholamine and monophenolamine agonists on identifiable giant neurones, sensitive to these amines, of an African giant snail (Achatina fulica Férussac)

The effects of 23 substances proposed as catecholamine (CA) and monophenolamine (MA) agonists were tested on the five CA-sensitive neurones, periodically oscillating neurone (PON), tonically autoactive neurone (TAN), left-visceral multiple spike neurone (1-VMN), dorsal-right pedal autoactive neurone (d-RPeAN) and visceral intermittently firing neurone (VIN), and the three MA-sensitive neurones, frequently autoactive neurone (FAN), dorsal-left pedal large neurone (d-LPeLN) and dorsal-left cerebral distinct neurone (d-LCDN), of an African giant snail (Achatina fulica Férussac). Of these neurones, PON, VIN and d-LPeLN were excited by the most effective catecholamine or monophenolamine, i.e. dopamine, epinine or DL-octopamine, whereas TAN, 1-VMN, d-RPeAN, FAN and d-LCDN were inhibited by the same substances. Of the five CA-sensitive neurones, PON and VIN were markedly excited by ergometrine (effective potency quotients (EPQs) of these substances as compared with the effective potency of the most effective catecholamine or monophenolamine for these neurones: 3.0 for PON, 1.0 for VIN), methylergometrine (EPQs: 3.0 for PON, 0.3 for VIN) and mescaline (EPQs: 0.3 for PON, 1.0 for VIN). These two neurones were excited slightly by DL-metaraminol (EPQs: 0.03 for both neurones) and DL-neosynephrine (EPQs: 0.03 for PON, 0.1 for VIN); VIN was also slightly sensitive to 3-methoxytyramine (EPQ: 0.03). TAN and 1-VMN were inhibited by ergometrine (EPQs: 1.0 for TAN, 0.3 for 1-VMN) and methylergometrine (EPQs: 0.3 for TAN, 0.1 for 1-VMN), whereas d-RPeAN was inhibited slightly only by DL-neosynephrine (EPQ: 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of catecholamines, monophenolamines and phenylamines on identifiable giant neurons of an African giant snail (Achatina fulica Férussac)

The effects of catecholamines, monophenolamines and phenylamines on eight identifiable giant neurons of an African giant snail (Achatina fulica Férussac) were examined to classify these neurons into several categories according to their sensitivities to the various substances. The five neurons, PON (periodically oscillating neuron), TAN (tonically autoactive neuron), 1-VMN (left-visceral multiple spike neuron), d-RPeAN (dorsal-right pedal autoactive neuron) and VIN (visceral intermittent firing neuron), were sensitive to catecholamines. Of these neurons, PON was excited most markedly by dopamine (dopamine-sensitive); TAN, 1-VMN and d-RPeAN were inhibited most markedly by epinine (epinine-sensitive); and VIN was excited equally by the four catecholamines, dopamine, epinine, L-noradrenaline and L-adrenaline (widely sensitive). The three other neurons, FAN (frequently autoactive neuron), d-LPeLN (dorsal-left pedal large neuron) and d-LCDN (dorsal-left cerebral distinct neuron) were sensitive to monophenolamines. DL-Octopamine was the most inhibitory on FAN and d-LCDN, but was the most excitatory on d-LPeLN. DL-Synephrine had the same but somewhat weaker effects on the three neurons as did DL-octopamine. The three phenylamines, L-phenylalanine, beta-phenylethylamine and DL-beta-phenylethanolamine, had no effect on any of the eight neurons examined.

Identification and pharmacological characteristics of the two giant neurons, v-RPLN and v-VNAN, on the ventral surface in the suboesophageal ganglia of the African giant snail (Achatina fulica Férussac)

Two giant neurons, v- RPLN (ventral-right parietal large neuron) and v- VNAN (ventral-visceral noisy autoactive neuron), were identified on the ventral surface in the caudal part of the suboesophageal ganglia of the African giant snail (Achatina fulica F erussac ), and their pharmacological features to the common putative neurotransmitters and their related substances were examined. The giant neuron examined, v- RPLN , is situated in front of the exit of the right anterior pallial nerve in the right parietal ganglion. The neuron, which is 250-300 microns in diameter, one of the largest neurons in the ganglia, was usually silent without spontaneous firing. The neuron was excited by L-norepinephrine (L-NE), DL-octopamine (DL-OA), 5-hydroxytryptamine (5-HT), L-homocysteic acid (L-HCA) and erythro-beta-hydroxy-L-glutamic acid (erythro-L- BHGA ); and inhibited by dopamine (DA), GABA, acetylcholine (Ach) and its related substances. Another giant neuron examined, v- VNAN , is situated very close to the right side of the exit of the right posterior pallial nerve in the visceral ganglion. The neuron is elliptical and about 150 micron in diameter. It showed spontaneous firing highly modified by the synaptic influences. DA, 5-HT, glycine (Gly), GABA and its related substances, L-HCA, erythro-L- BHGA , and Ach and its related substances all had the direct (not via synaptic influences) excitatory effects on the neuromembrane examined. Some of them, for example, L-NE, 5-HT and Ach and its related substances caused transient excitation of the neuron, probably due to the synaptic influences, immediately after their application. No substance producing any inhibition of the neuron could be found in the present study.

Effects of synthetic ergot derivatives on the two identifiable giant neurons, sensitive to dopamine, of Achatina fulica Ferussac

On the two dopamine (DA)-sensitive giant neurones, PON (periodically oscillating neuron, excited by DA) and TAN (tonically autoactive neuron, inhibited by DA), of an African giant snail (Achatina fulica Férussac), effects of synthetic ergot derivatives, including lisuride and pergolide, which are considered to be dopamine agonists, were examined. Of the substances examined, three of the ergot derivatives related to pergolide, D-8,9-didehydro-6-propylergoline-8-methanol (LY149174), D-6-methyl-8 beta-(2-(methylsulfinyl)ethyl)ergoline (LY116470) and D-2-chloro-6-methyl-8 beta-(2-(methylsulfinyl)ethyl)ergoline (LY127817), showed excitatory effects on PON, while pergolide (D-8 beta-( (methylthio)methyl)-6-propylergoline, LY127809) and lisuride (N-D-6-methyl-8-isoergolenyl-N',N'-diethylcarbamide) had no effect. On the other hand, only D-6-methyl-8 beta-(2-(methylsulfinyl)ethyl)ergoline (LY116470) had any excitatory effects on TAN.

Identification of three further giant neurons, r-APN, INN and FAN, in the caudal part on the dorsal surface of the suboesophageal ganglia of Achatina fulica Férussac

In addition to the neurons of Achatina fulica Férussac examined previously, three more giant neurons, r-APN (right-anterior pallial neurons), INN (intestinal nerve neuron) and FAN (frequently autoactive neuron), were identified in the suboesophageal ganglia of the same animal. R-APN (200-250 microns in diameter), the somatic membrane of which was usually silent, was found near the exit of the right anterior pallial nerve in the right parietal ganglion. The most important feature in identifying the neuron is the one-by-one correspondence of somatic spikes to impulses in the right anterior pallial and the left anterior pallial nerves. R-APN was excited markedly by dopamine, 5-hydroxytryptamine, L-homocysteic acid, erythro-beta-hydroxy-L-glutamic acid and acetylcholine, and inhibited by GABA. INN (150-200 microns in diameter), which was also silent, was situated near the intestinal nerve in the visceral ganglion. INN somatic spikes corresponded to the impulses in the intestinal nerve. INN was excited by 5-hydroxytryptamine and histamine. Acetylcholine had biphasic effects (inhibitory followed by slight excitatory). FAN (100-150 microns in diameter), showing frequent spike discharges, about 60-120/min, was situated somewhat further from the exit of the left posterior pallial nerve in the visceral ganglion. No clear correspondence was observed between the FAN somatic spikes and impulses of any nerves. FAN was excited by 5-hydroxytryptamine, GABA and acetylcholine, and inhibited by octopamine and erythro-beta-hydroxy-L-glutamic acid.