Cumulative risk assessment for combinations of environmental and psychosocial stressors: A systematic review

With the growing awareness of stressors, cumulative risk assessment (CRA) has been proposed as a potential method to evaluate possible additive and synergistic effects of multiple stressors on human health, thus informing environmental regulation and protecting public health. However, CRA is still in its exploratory stage due to the lack of generally accepted quantitative approaches. It is an ideal time to summarize the existing progress to guide future research. To this end, a systematic review of the literature on CRA issues dealing with combinations of environmental and psychosocial stressors was conducted in this study. Using typology and bibliometric analysis, the body of knowledge, hot topics, and research gaps in this field were characterized. It was found that research topics and objectives mainly focus on qualitative analysis and community settings; more attention should be paid to the development of quantitative approaches and the inclusion of occupational settings. Further, the roles of air pollution and vulnerability factors in CRA have attracted the most attention. This study concludes with views on future prospects to promote theoretical and practical development in this field; specifically, CRA is a multifaceted topic that requires substantial collaborations with various stakeholders and substantial knowledge from multidisciplinary fields. This study presents an overall review as well as research directions worth investigating in this field, which provides a historical reference for future study. Integr Environ Assess Manag 2024;20:602-615. © 2023 SETAC.

The association between incarceration and housing insecurity and advanced immune age during late life

Emerging evidence suggests that psychosocial stress ages the immune system. Accordingly, immune aging may be an important potential mechanism linking psychosocial stress to aging-related decline and disease. Incarceration and housing insecurity represent severe and complex experiences of a multitude of psychosocial stressors, including discrimination, violence, and poverty. In this study, we investigated the association between incarceration and/or housing insecurity and advanced immune age in adults aged 55 and older. Our sample was derived from the Health and Retirement Survey (HRS), with n = 7003 individuals with valid housing insecurity data and n = 7523 with valid incarceration data. From 2016 Venous Blood Study data, we assessed immune aging using a comprehensive set of immune markers including inflammatory markers (IL-6, CRP, s-TNFR1), markers of viral control (CMV IgG antibodies), and ratios of T cell phenotypes (CD8+:CD4+, CD+ Memory: Naïve, CD4+ Memory: Naïve, CD8+ Memory: Naïve ratios). We found that both incarceration and housing insecurity were strongly associated with more advanced immune aging as indicated by increased inflammation, reduced viral control, and reduction in naïve T cells relative to memory T cells. Given that those who experienced incarceration, housing insecurity, and/or are racialized minorities were less likely to be included in this study, our results likely underestimated these associations. Despite these limitations, our study provided strong evidence that experiencing incarceration and/or housing insecurity may accelerate the aging of the immune system.

Stress, Environment and Early Psychosis

Existing literature provides extended evidence of the close relationship between stress dysregulation, environmental insults, and psychosis onset. Early stress can sensitize genetically vulnerable individuals to future stress, modifying their risk for developing psychotic phenomena. Neurobiological substrate of the aberrant stress response to hypothalamic-pituitary-adrenal axis dysregulation, disrupted inflammation processes, oxidative stress increase, gut dysbiosis, and altered brain signaling, provides mechanistic links between environmental risk factors and the development of psychotic symptoms. Early-life and later-life exposures may act directly, accumulatively, and repeatedly during critical neurodevelopmental time windows. Environmental hazards, such as pre- and perinatal complications, traumatic experiences, psychosocial stressors, and cannabis use might negatively intervene with brain developmental trajectories and disturb the balance of important stress systems, which act together with recent life events to push the individual over the threshold for the manifestation of psychosis. The current review presents the dynamic and complex relationship between stress, environment, and psychosis onset, attempting to provide an insight into potentially modifiable factors, enhancing resilience and possibly influencing individual psychosis liability.

The relationship between disease-specific psychosocial stressors and depressive symptoms in Huntington's disease

BACKGROUND

Huntington's disease (HD) is an inherited neurodegenerative disease involving motor abnormalities, cognitive decline, and psychological difficulties. Depression is among the most common psychological difficulties in HD. People with HD encounter numerous stressors related to their diagnosis and the impact of HD on their daily lives. Understanding the relationship between HD-specific psychosocial stressors and depression symptoms is critical for optimising treatment and developing a holistic, disease-specific model of depression in HD.

METHODS

Fifty-seven adults with the HD gene expansion (33 pre-symptomatic, 24 symptomatic) completed a self-report depression questionnaire and rated how much stress they experienced in relation to 20 psychosocial challenges commonly associated with HD. We examined associations between depression symptoms and each stressor individually, and after clustering using principal components analysis.

RESULTS

Depression symptoms were significantly associated with most of the psychosocial stressors assessed. Clustering with principal components analysis revealed that higher depression scores had significant independent associations with greater stress related to the future implications of HD (β = .44, p = .001) and sleep and psychological difficulties (β = .28, p = .005), but not with stress related to functional limitations (β = .11, p = .33) or interpersonal issues caused by HD (β = .15, p = .21).

CONCLUSIONS

Stressful experiences associated with HD constitute an important risk factor for depression in HD. Our findings support the use of more psychologically informed models of depression in HD and necessitate further research on tailored psychosocial interventions for HD patients with depression.

Prevalence and comparison of psychological trauma and stressors in functional seizure patients from a public and private hospital

PURPOSE

To date not much is known about the differences, if any, between patients with functional seizures (FS) from different socioeconomic backgrounds. We sought to compare the psychological stress and trauma profiles of patients with FS from a private and public hospital in Cape Town, South Africa.

METHODS

Only video-electroencephalography-confirmed patients with FS were eligible for the study. In this retrospective case-control study we collected data on self-reported demographic and psychological stressor/trauma variables using digital patient records starting with the earliest available digital patient record for each hospital.

RESULTS

A total of 321 patients from a private hospital and 68 patients from a public hospital were included in the study. Most factors showed no significant differences. However, public hospital patients had higher odds of being older (p = 0.002), almost nine times the odds of reporting physical violence by an intimate partner (aOR = 8.65, 95% CI [1.70, 44.08]), more than eight times the odds of reporting psychological stress in the form of death and/or sickness in the family (aOR = 8.56, 95% CI [1.81, 40.41]) and almost three times the odds for other general psychosocial stressors (aOR = 2.82, 95% CI [1.08, 7.42]) compared to those attending the private hospital. They also had half the odds of being female compared to the private hospital patients (aOR = 0.47, 95% CI [0.23, 0.95]) and 93% fewer odds of reporting coming from an abusive home (aOR = 0.07, 95% CI [0.01, 0.52]).

CONCLUSION

History and psychological trauma and stressor profiles showed many similarities between the public and private hospital groups; however, some differences were noted and could benefit further exploration and consideration in therapeutic and diagnostic contexts.

Longitudinal plasmode algorithms to evaluate statistical methods in realistic scenarios: an illustration applied to occupational epidemiology

INTRODUCTION

Plasmode simulations are a type of simulations that use real data to determine the synthetic data-generating equations. Such simulations thus allow evaluating statistical methods under realistic conditions. As far as we know, no plasmode algorithm has been proposed for simulating longitudinal data. In this paper, we propose a longitudinal plasmode framework to generate realistic data with both a time-varying exposure and time-varying covariates. This work was motivated by the objective of comparing different methods for estimating the causal effect of a cumulative exposure to psychosocial stressors at work over time.

METHODS

We developed two longitudinal plasmode algorithms: a parametric and a nonparametric algorithms. Data from the PROspective Québec (PROQ) Study on Work and Health were used as an input to generate data with the proposed plasmode algorithms. We evaluated the performance of multiple estimators of the parameters of marginal structural models (MSMs): inverse probability of treatment weighting, g-computation and targeted maximum likelihood estimation. These estimators were also compared to standard regression approaches with either adjustment for baseline covariates only or with adjustment for both baseline and time-varying covariates.

RESULTS

Standard regression methods were susceptible to yield biased estimates with confidence intervals having coverage probability lower than their nominal level. The bias was much lower and coverage of confidence intervals was much closer to the nominal level when considering MSMs. Among MSM estimators, g-computation overall produced the best results relative to bias, root mean squared error and coverage of confidence intervals. No method produced unbiased estimates with adequate coverage for all parameters in the more realistic nonparametric plasmode simulation.

CONCLUSION

The proposed longitudinal plasmode algorithms can be important methodological tools for evaluating and comparing analytical methods in realistic simulation scenarios. To facilitate the use of these algorithms, we provide R functions on GitHub. We also recommend using MSMs when estimating the effect of cumulative exposure to psychosocial stressors at work.

Nursing students' academic conditions, psychological distress, and intention to leave school: A cross-sectional study

BACKGROUND

Psychological distress and intention to leave school are highly prevalent among nursing students. Academic conditions, including psychosocial stressors and school-work-life conflicts, could contribute to psychological distress and intention to leave school.

OBJECTIVE

To explore the associations between academic conditions and 1) psychological distress and 2) intention to leave school.

DESIGN

Cross-sectional correlational design.

SETTINGS

Data collection was performed in February and October 2021 in two nursing schools in Canada: Cegep (publicly funded college, technical degree) and university (bachelor's degree).

PARTICIPANTS

230 nursing students (Cegep 131, university 99).

METHODS

A self-administered online questionnaire assessed academic conditions (psychosocial stressors (Demand-Control-Support, Effort-Reward Imbalance and Overcommitment scales) and school-work-life conflicts (single item)), psychological distress (Kessler-6 scale), intention to leave school, and several covariates. Poisson robust multivariate regression models were built to explore the associations between academic conditions and 1) psychological distress and 2) intention to leave school.

RESULTS

A large proportion of participants experienced high efforts, school-work-life conflicts, overcommitment, and psychological distress (49.5-84.7 %). One out of five participants had had intention to leave school "many times" (Cegep 20.61 %; university 22.22 %). In adjusted analysis, overcommitment and school-work-life conflicts were associated with a higher prevalence of psychological distress (Prevalence ratio = 2.10; 95 % Confidence Intervals = 1.15-3.84 and Prevalence ratio = 2.32; 95 % Confidence Intervals = 1.24-4.32, respectively). Adverse associations were observed between effort-reward imbalance (Prevalence ratio = 2.32; 95 % Confidence Intervals = 1.09-4.94) as well as school-work-life conflicts (Prevalence ratio = 2.40; 95 % Confidence Intervals = 1.05-5.45) and intention to leave school.

CONCLUSIONS

Academic conditions might be risk factors for psychological distress and intention to leave school among nursing students. Interventions targeting modifiable academic conditions might improve nursing students' mental health and retention.

Psychosocial stressors and current e-cigarette use in the youth risk behavior survey

BACKGROUND

This study explores the association between psychosocial stressors and current e-cigarette use among adolescents in the United States.

METHODS

We used data from 12,767 participants in the 2019 National Youth Risk Behavioral Survey to examine the association between psychosocial stressors (bullying, sexual assault, safety-related absence from school, depressive symptoms, suicidal ideation, physical altercation, and weapon threats) and past-30-day e-cigarette use using multivariable-adjusted logistic regression models. We examined the association for each stressor and then as a burden score (0-7). To compare the strength of the association between stressors and current e-cigarette use to current combustible cigarette use, we additionally examined the association between each stressor and current combustible cigarette use.

RESULTS

Approximately 32.7% reported current e-cigarette use. The weighted prevalence of current e-cigarette use was higher among individuals who experienced stressors than those who did not. For example, bullying (43.9% vs. 29.0%). Similar prevalence patterns were seen among other stressors. Individuals who experienced stressors had significantly higher adjusted odds of current e-cigarette use than those who did not (OR [Odds Ratio] range: 1.47-1.75). Similarly, individuals with higher burden scores had a higher prevalence (zero [20.5%], one [32.8%], two [41.4%], three [49.6%], four to seven [60.9%]) and higher odds of current e-cigarette use (OR range: 1.43-2.73) than those with a score of zero. The strength of the association between the stressors and e-cigarette use was similar to that between the stressors and combustible cigarette use.

CONCLUSION

The study demonstrates a significant association between psychosocial stressors and adolescent e-cigarette use, highlighting the potential importance of interventions, such as targeted school-based programs that address stressors and promote stress management, as possible means of reducing adolescent e-cigarette use. Future research directions include exploring underlying mechanisms linking stressors to e-cigarette use and evaluating the effectiveness of interventions addressing stressors in reducing adolescent e-cigarette use.

[Suicide prevention in the context of assisted suicide]

The verdict of the German Federal Constitutional Court from 26 February 2020 made it clear that every person is granted the right to end his or her own life, provided it is the person's own free will. It is also within his or her rights to utilize assistance in doing so, if such assistance is offered. This freedom to end one's life and to utilize assistance is not limited to terminal illnesses or situations of unbearable suffering. However, the High Court has also demanded that lawmakers ensure the safety of vulnerable people by making certain that the decision for suicide is in fact made out of the person's own free will. This free decision-making capability can be substantially impaired by acute psychosocial stressors, by mental illnesses but also by third party influence. Therefore, a liberalization of assisted suicide must unconditionally be accompanied by a massive strengthening of suicide prevention measures, which clearly prioritize the help to live over the help to die. This article reviews the scientifically established methods for suicide prevention and makes demands to lawmakers to comprehensively implement such measures.

Measuring psychosocial stress during pregnancy: a multiple-group confirmatory factor analysis across race/ethnicity among Medicaid-covered pregnant women in the United States

BACKGROUND

Differential experiences of psychosocial stress during pregnancy may contribute to racial inequities in adverse pregnancy outcomes in the US. Valid and unbiased measurement scales are needed to assess the effect of psychosocial stress on pregnancy outcomes, however, the numerous modified scales implemented to measure stress are not always validated.

METHODS

The construct validity and measurement invariance of maternal stress among Medicaid-covered pregnant women (N = 1,632) were examined. Model fit estimates of three confirmatory factor analysis (CFA) models were compared to determine the appropriate measurement structure. Multiple-group CFA assessed measurement invariance across Black or African American women (51.7%) and women of all other races.

RESULTS

Robust estimates of model fit supported a hierarchical CFA model composed of four latent domains of stress. Standardized factor loadings of three of these latent domains-external stress, perceived stress, and enhancers of stress- indicated positive correlations with a second-order latent factor for overall maternal stress, whereas the fourth domain, buffers of stress, had a negative association. Multiple-group CFA demonstrated strong measurement invariance.

CONCLUSIONS

Among Medicaid-covered pregnant women, measures for psychosocial stress were unbiased across two subgroups of maternal race/ethnicity. These findings support the construct validity of overall maternal stress underlying the common variability among four latent domains of stress.

Ophthalmic sequelae and psychosocial impact in pediatric ebola survivors

Background

Ebola virus disease (EVD) outbreaks in West Africa (2013-2016) and the Democratic Republic of Congo (2018-2020) have resulted in thousands of EVD survivors who remain at-risk for survivor sequelae. While EVD survivorship has been broadly reported in adult populations, pediatric EVD survivors are under-represented. In this cross-sectional study, we investigated the prevalence of eye disease, health-related quality-of-life, vision-related quality-of-life, and the burden of mental illness among pediatric EVD survivors in Sierra Leone.

Methods

Twenty-three pediatric EVD survivors and 58 EVD close contacts were enrolled. Participants underwent a comprehensive ophthalmic examination and completed the following surveys: Pediatric Quality of Life Inventory Version 4.0, Effect of Youngsters Eyesight on Quality-of-Life, and the Revised Child Anxiety and Depression Scale.

Findings

A higher prevalence of uveitis was observed in EVD survivor eyes (10·8%) cohort compared to close contacts eyes (1·7%, p=0·03). Overall, 47·8% of EVD survivor eyes and 31·9% of close contact eyes presented with an eye disease at the time of our study (p=0·25). Individuals diagnosed with an ocular complication had poorer vision-related quality-of-life (p=0·02).

Interpretation

Both health related quality-of-life and vision-related quality-of-life were poor among EVD survivors and close contacts. The high prevalence of eye disease associated with reduced vision health, suggests that cross-disciplinary approaches are needed to address the unmet needs of EVD survivors.

Funding

National Institutes of Health R01 EY029594, K23 EY030158; National Eye Institute; Research to Prevent Blindness (Emory Eye Center); Marcus Foundation Combating Childhood Illness; Emory Global Health Institute; Stanley M. Truhlsen Family Foundation.

Acute cardiovascular events triggered by the COVID-19 pandemic-related stress in non-infected individuals. The Jordan COVID-19 Acute Cardiovascular Events (JoCORE) study

The Corona Virus Disease 2019 (COVID-19) has become an unprecedented global public health crisis and a pandemic associated with vicarious psychosocial and economic stresses. Such stresses were reported to lead to behavioral and emotional disturbances in individuals not infected with the COVID-19 virus. It is largely unknown if these stresses can trigger acute cardiovascular events (CVE) in such individuals. Covid-19-neagtive adults presenting with acute myocardial infarction (AMI), cerebrovascular accident (CVA), or out-of-hospital cardiac arrest (OHCA) during the COVID-19 pandemic in Jordan from March 15, 2020 through March 14, 2021 were enrolled in the study if they reported exposure to psychosocial or economic stresses related to the pandemic lockdown. Of 300 patients enrolled (mean age 58.7 ± 12.9 years), AMI was diagnosed in 269 (89.7%) patients, CVA in 15 (5.0%) patients, and OHCA in 16 (5.3%) patients. Triggering events were psychosocial in 243 (81.0%) patients and economic stressors in 157 (52.3%) patients. The psychosocial stresses included loneliness, hopelessness, fear of COVID-19 infection, anger, and stress-related to death of a significant person. The economic stressors included financial hardships, job loss or insecurity, volatile or loss of income. Exposure to more than one trigger was reported in 213 (71.0%) patients. In-hospital mortality of the patients admitted for AMI or CVA was 2.1%, and none of the OHCA survived the event. The COVID-19 pandemic continues to be a source of significant psychosocial and economic hardships that can trigger life-threatening acute CVE among individuals not infected with the virus.

The prevalence of depression, stress and anxiety symptoms in patients with chronic heart failure

Background

Mental health illnesses are associated with frequent hospitalisation and an increased risk of all-cause mortality. Despite the high prevalence of depression in patients with chronic heart failure (CHF), there is a paucity of data on this subject from low and middle-income countries (LMIC). The aim of this study was to determine the prevalence of depression, anxiety, and stress symptoms in patients attending a dedicated CHF clinic.

Methods

A prospective study was conducted at an outpatient heart failure clinic in a tertiary academic centre. The study participants completed a Depression, Anxiety and Stress (DASS-21) questionnaire to screen for the presence and severity of depression, anxiety and stress symptoms. Furthermore, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) was completed and used to evaluate the impact of CHF on health-related quality of life (QoL). Descriptive statistics were used to describe patients' characteristics and logistic regression analysis to identify predictors of symptoms of depression.

Results

The study population comprised of 103 patients, predominantly female (62.1%) with a median age of 53 (interquartile range 38–61) years. Symptoms of depression were reported by 52.4%, with 11.6% reporting symptoms suggestive of extremely severe depression. Anxiety was diagnosed in 53.4% of patients and extremely severe anxiety was reported by 18.4% of patients. Fifty patients were classified as stressed, and only 7.7% had extremely severe stress. More than half of the patients (54.4%) were in New York Heart Association functional class I. The mean left ventricular ejection fraction in the entire cohort was 30% (SD =  ± 11.1%). In the multivariable logistic regression model, the MLHFQ score [odds ratio (OR) 1.04, 95% CI:1.02–1.06, p = 0.001] and the six-minute walk test [OR 0.99, 95% CI: 0.98–0.99, p = 0.014] were identified as independent predictors of depression.

Conclusion

Depression and anxiety symptoms were found in over half of patients attending the CHF clinic. We recommend that mental health screening should be routinely performed in patients with CHF. Prospective, adequately powered, multicentre studies from LMIC investigating the impact of depression, anxiety and stress on CHF outcomes such as health-related QoL, hospitalisation and mortality are required.

COVID-19 Pandemic and Uptake in Suicide Attempt Among Young People of Minority Population: A Case Series

The first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan China on December 31, 2019. COVID-19 was declared a global pandemic on March 11, 2020. To reduce the spread of this virus, the World Health Organization (WHO) and the Center for Disease Control (CDC) recommended self and mandatory quarantine of exposed individuals and self-isolation. However, the psychological impact of this pandemic includes new onset or worsening of existing mental illnesses which include but are not limited to anxiety, depression from social isolation, eating disorders, and uptake in suicidality either in isolation or part of mental illness symptomatology. In the USA, suicide is the second leading cause of death among people aged 10 - 34 years while globally, it is the second cause of death among people aged 15 - 29 years. The authors present a case of two young women of minority population with no prior psychiatric illnesses who presented to the psychiatry emergency room with suicidal attempts due to COVID-19 pandemic-related psychosocial stressors.

Parental psychosocial aspects and stressors involved in the management of inborn errors of metabolism

Parents of children with inborn errors of metabolism (IEM) face numerous psychosocial challenges. An increased understanding and awareness of these stressors can ensure better overall outcomes for the entire family. We conducted semi-structured, in-person interviews with ten parents to identify psychosocial stressors, strategies, and supports they utilized to overcome their challenges. Our interview guide was designed to elicit familial experiences during the pre- and post-diagnosis periods. The themes and sub-themes were identified through qualitative descriptive textual analysis of audio-recorded transcripts. Major themes identified include ambiguity of illness, changing family and spousal dynamics, and navigating the healthcare system. Sub-themes revolved around disease effects, psychological stressors, health systems, support, and facing the disease. Healthcare professionals have an opportunity to minimize the impact of negative emotional outcomes by assisting families as they navigate the experience of having a child with an IEM. Our findings can be used to develop and continue a more well-rounded, family-oriented framework for IEM management.

The effect of occupational stress on depression and insomnia: a cross-sectional study among employees in a Ghanaian telecommunication company

BACKGROUND

Depression and insomnia are major psychiatric conditions predicted by occupational stress. However, the influence of occupational stress on these two conditions is under-explored in telecommunication companies, especially in Africa. This research was conducted to assess occupational stress in a Ghanaian telecommunication company and its effect on depression and insomnia.

METHODS

An analytical cross-sectional study was conducted among employees at a telecommunication company in Accra. Structured self-administered questionnaires were used in collecting data from 235 respondents using simple random sampling. The Chi-square test of independence and Wilcoxon Rank-Sum test were employed to assess the significance of associations with subsequent sensitivity analysis using Multiple logistic, Poisson and Probit regression models. Occupational stress was matched on four variables: age of the workers, marital status, responsibility for dependents and work experience, to improve on the estimation of its impact on symptomatic depression and insomnia using the coarsened exact matching procedure.

RESULTS

More males (52.8%) than females participated in this study. The age range for study participants was 20-49 years with a mean of 30.8 ± 6.9 years. The prevalence of excessive occupational stress reported by the employees was 32.8% (95% CI = 26.7-38.8). More than half of respondents (51%) reported depressive symptoms in the past week and only a few (6%) reported being diagnosed with insomnia in the past year. Age, responsibility for dependents and work experience were the only background characteristics that were significantly associated with excessive occupational stress. After controlling for background characteristics, the estimated risk of reporting symptoms of depression among employees who reported excessive stress from work was only 5% higher [ARR; 95% CI = 1.05 (0.94-1.17)] whereas it was 2.58 times the risk of reporting insomnia [ARR; 95% CI = 2.58(0.83-8.00)] compared to those who did not report excessive stress from their jobs. The relative risk reduced to 2.46[ARR; 95% CI = 2.46(0.77-7.87)] and 1.03[ARR; 95% CI = 1.03(0.91-1.17)] for insomnia and depression respectively after employing Poisson regression with CEM.

CONCLUSION

The study found a higher risk of insomnia among employees who reported excessive occupational stress compared to those who did not. However, this study did not find a statistically significant relationship between depression and occupational stress.

Mental wellbeing among Hispanic female domestic cleaners

BACKGROUND

The purpose of this study was to examine the mental wellbeing of self-employed, Hispanic female domestic cleaners in San Antonio, Texas.

METHODS

We conducted a cross-sectional pilot study and administered a short questionnaire to 56 participants. Mental wellbeing was assessed using The World Health Organization Well-Being Index (WHO-5). We calculated the age-adjusted prevalence of poor mental wellbeing, both overall and stratified by socioeconomic, neighborhood, and health characteristics.

RESULTS

Almost half of the participants screened positive for poor mental wellbeing (47.3%) with a mean WHO-5 score of 68.9 [standard error (SE) = 3.1]. We observed a high prevalence of poor mental wellbeing among participants with less than a high school education (56.0%), who worked less than 30 h per week (57.0%) and who sometimes or always felt unsafe at her cleaning job (69.1%).

CONCLUSIONS

Female domestic cleaners, particularly those who work in the informal sector, are an overburdened and understudied population. This is particularly true regarding their mental wellbeing, which has largely been considered as an afterthought in epidemiologic studies of cleaning workers in general. Our results suggest that this group of domestic cleaners faces several psychosocial stressors, both in and outside of the workplace, and may have a high risk of poor mental health outcomes.

Psychosocial Stress and Overweight and Obesity: Findings From the Chicago Community Adult Health Study

BACKGROUND

Psychosocial stress has been implicated as a risk factor for overweight and obesity. However, research on psychosocial stressors and overweight and obesity has typically focused on single stressors in isolation, which may overestimate the impact of a specific stressor and fail to describe the role of cumulative stress on overweight and obesity risk.

PURPOSE

This study explores the association between overweight/obesity and cumulative exposure to a wide range of psychosocial stressors, among a multiracial/ethnic sample of adults.

METHODS

Using secondary data from the Chicago Community Adult Health Study (n = 2,983), we conducted multinomial logistic regression analyses to quantify associations between eight psychosocial stressors, individually and in combination, and measured overweight and obesity, adjusted for sociodemographic factors, alcohol use and smoking.

RESULTS

In separated covariate-adjusted models, childhood adversities (odds ratio [OR] = 1.16; confidence interval [CI] = [1.03, 1.30]), acute life events (OR = 1.18; CI = [1.04, 1.34]), financial strain (OR = 1.30; CI = [1.15, 1.47]), and relationship stressors (OR = 1.18; CI = [1.04, 1.35]) were associated with increased odds of obesity. In a model adjusted for all stressors simultaneously, financial strain was the only stressor independently associated with overweight (OR = 1.17; CI = [1.00, 1.36]) and obesity (OR = 1.21; CI = [1.05, 1.39]). Participants with stress exposure in the highest quintile across 2, 3, or ≥4 (compared to no) types of stressors had significantly higher odds of obesity.

CONCLUSIONS

Multiple types of stressors may be risk factors for obesity, and cumulative exposure to these stressors may increase the odds of obesity. Reducing exposure to stressors at the population level may have the potential to contribute to reducing the burden of obesity.

An investigation of racial/ethnic and sex differences in the association between experiences of everyday discrimination and leukocyte telomere length among patients with coronary artery disease

Leukocyte telomere length (LTL) may be sensitive to psychosocial stressors such as discrimination. An inclusive examination of experiences of discrimination on LTL across racial/ethnic and sex groups is currently lacking. Baseline data were obtained from 369 White and African American patients with coronary artery disease (CAD) in the Mental Stress Ischemia Mechanisms and Prognosis Study. LTL was measured from peripheral blood leukocytes by quantitative polymerase chain reaction and calculated in kilobase pairs. Discrimination was measured using the 10-item Everyday Discrimination Scale (EDS). Responses were rated using 4-point Likert scales ranging from never = 1 to often = 4 and summed. Regression models were stratified by race/ethnicity and sex to estimate associations between discrimination and LTL. Each 10-unit increase in experiences of everyday discrimination was associated with an average of .20 fewer kilobase pairs (or 200 base pairs) among both African American women (β = -0.19; 95% CI: -0.35, -0.04; p-value: 0.02) and White women (β = -0.19; 95% CI: -0.37, -0.01; p-value: 0.04), after adjusting for basic demographic factors. Results were similar after further adjusting for behavioral, disease, and psychosocial risk factors (depression and stress). There were no significant associations between experiences of everyday discrimination and LTL for White men or African American men. Overall, experiences of discrimination were associated with shorter LTL among women and not in men. Discrimination may be a potential source of stress associated with shorter LTL among women with CAD. Future studies should explore longitudinal associations between everyday experiences of discrimination and telomere length and also with adverse cardiovascular outcomes.

Racial/Ethnic Inequities in Low Birth Weight and Preterm Birth: The Role of Multiple Forms of Stress

Introduction Racial/ethnic inequities in low birth weight (LBW) and preterm birth (PTB) persist in the United States. Research has identified numerous risk factors for adverse birth outcomes; however, they do not fully explain the occurrence of, or inequalities in PTB/LBW. Stress has been proposed as one explanation for differences in LBW and PTB by race/ethnicity. Methods Using the Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2013 for 21 states and one city (n = 15,915) we used Poisson regression to estimate the association between acute, financial and relationship stressors and LBW and PTB, and to examine the contribution of these stressors individually and simultaneously to racial/ethnic differences in LBW and PTB. Results Adjusting for age and race/ethnicity, acute (p < 0.001), financial (p < 0.001) and relationship (p < 0.05) stressors were associated with increased risk of LBW, but only acute (p < 0.05) and financial (p < 0.01) stress increased risk of PTB. Across all models, non-Hispanic blacks had higher risk of LBW and PTB relative to non-Hispanic whites (IRR 1.87, 95% CI 1.55, 2.27 and IRR 1.46, 95% CI 1.18, 1.79). Accounting for the effects of stressors attenuated the risk of LBW and PTB by 17 and 22% respectively, but did not fully explain the increased likelihood of LBW and PTB among non-Hispanic blacks. Discussion Results of this study demonstrate that stress may increase the risk of LBW and PTB. While stressors may contribute to racial/ethnic differences in LBW and PTB, they do not fully explain them. Mitigating stress during pregnancy may help promote healthier birth outcomes and reduce racial/ethnic inequities in LBW and PTB.

Experiences of Discrimination Are Associated With Greater Resting Amygdala Activity and Functional Connectivity

BACKGROUND

Social discrimination, a type of psychological stressor, is associated with poorer physical and mental health outcomes, yet we have little understanding of how discrimination affects neural functions in marginalized populations. By contrast, the effects of psychological stress on neural functions are well documented, with evidence of significant effects on the amygdala-a neural region that is central to psychosocial functions. Accordingly, we conducted an examination of the relation between self-reported discrimination exposure and amygdala activity in a diverse sample of adults.

METHODS

Seventy-four adults (43% women; 72% African American; 23% Hispanic; 32% homosexual/bisexual) completed self-report ratings of discrimination exposure. Spontaneous amygdala activity and functional connectivity were assessed during resting-state functional magnetic resonance imaging.

RESULTS

Greater discrimination exposure was associated with higher levels of spontaneous amygdala activity. Increases in discrimination were also associated with stronger functional connectivity between the amygdala and several neural regions (e.g., anterior insula, putamen, caudate, anterior cingulate, medial frontal gyrus), with the most robust effects observed in the thalamus. These effects were independent of several demographic (e.g., race, ethnicity, sex) and psychological (e.g., current stress, depression, anxiety) factors.

CONCLUSIONS

Collectively, our findings provide the first evidence that social discrimination is independently associated with elevations in intrinsic amygdala activity and functional connectivity, thus revealing clear parallels between the neural substrates of discrimination and psychological stressors of other origins. Such results should spur future investigations of amygdala-based networks as potential etiological factors linking discrimination exposure to adverse physical and mental health outcomes.

Psychosocial stressors contributing to emergency psychiatric service utilization in a sample of ethno-culturally diverse clients with psychosis in Toronto

BACKGROUND

Understanding the psychosocial stressors of people with psychoses from minority ethnic groups may help in the development of culturally appropriate services. This study aimed to compare psychosocial factors associated with attendance at an emergency department (ED) for six ethnic groups. Preventing crises or supporting people better in the community may decrease hospitalization and improve outcomes.

METHOD

A cohort was created by retrospective case note analysis of people of East-Asian, South-Asian, Black-African, Black-Caribbean, White-North American and White-European origin groups attending a specialized psychiatric ED in Toronto with a diagnosis of psychosis between 2009 and 2011. The psychological or social stressors which were linked to the presentation at the ED that were documented by the attending physicians were collected for this study. Logistic regression models were constructed to analyze the odds of presenting with specific stressors.

RESULTS

Seven hundred sixty-five clients were included in this study. Forty-four percent of the sample did not have a psychiatrist, and 53% did not have a primary care provider. Social environmental stressors were the most frequent psychosocial stressor across all six groups, followed by issues in the primary support group, occupational and housing stressors. When compared to White-North American clients, East-Asian and White-European origin clients were less likely to present with a housing stressor, while Black-African clients had decreased odds of presenting with primary support group stressor. Having a primary care provider or psychiatrist were predominantly protective factors.

CONCLUSION

In Toronto, moving people with chronic mental health conditions out of poverty, increasing the social safety net and improving access to primary care and community based mental health services may decrease many of the stressors which contribute to ED attendance.

Psychosocial Stress, Health, and the Hippocampus

Psychoneuroimmunology (PNI) is an interdisciplinary field that examines the relationships between psychological factors and changes in endocrine and immune function, with possible consequences for health status. There is a growing literature suggesting that psychosocial stressors can impact negatively on health through deleterious changes in immune function. In their 2005 review, Glaser and Kiecolt-Glaser examined the mechanisms by which these changes might occur, and summarized some of the findings showing stress-related health consequences in a number of human populations. Buchanan et al. (2009) examined the cortisol response in individuals sustaining damage to the hippocampus, when challenged with a psychosocial stressor. Individuals with damage to the hippocampus, but not those with damage in other regions of the brain, showed abnormal cortisol responses to the psychosocial stressor. These papers were used successfully in an undergraduate Neuroscience course to stimulate class discussion; other possible uses for these articles are discussed.

Prevalence of depression in type 2 diabetes patients in German primary care practices

AIMS

To analyse depression in German type 2 diabetes patients with or without diabetes complications.

METHODS

Longitudinal data from nationwide general practices in Germany (n=1,202) were analysed. People initially diagnosed with type 2 diabetes (2004-2013) were identified and 90,412 patients were included (age: 65.5 years, SD: 11.7). The main outcome measure was the first diagnosis of depression (ICD 10: F32, F33) within ten years after index date in patients with and without diabetes complications. Cox proportional hazards models were used to adjust for confounders.

RESULTS

At baseline, most patients had diabetes complications and 6.4% of them had private insurance. Ten years after type 2 diabetes diagnosis, 30.3% of patients showed symptoms of depression. The prevalence of depression was higher in women than in men (33.7% versus 26.8%), in patients with high HbA1c levels (31.3% when Hb1Ac ≥ 9 versus 27.5% when HbA1c < 7) and in patients with diabetes complications (37.7% when there were more than two complications versus 29.1% when there were no complications). Women and patients without private health insurance were at a higher risk of developing depression. Retinopathy, neuropathy, nephropathy, coronary heart disease, stroke and HbA1c levels higher than 7 were also positively associated with depression.

CONCLUSIONS

Diabetes complications and high HbA1c levels had a substantial impact on depression in primary care patients with type 2 diabetes.

Alone in the Crowd: I Failed the ABGC Certification Exam

The American Board of Genetic Counseling (ABGC) certification examination (often referred to as "the board exam") has become a milestone within the field of genetic counseling. For many, it is the final standardized test taken and indicates the examinee has met "the standards of minimal competence to practice as a genetic counselor" (Bulletin 2015). Although voluntary, certification is strongly encouraged, and in some employment situations, required. Although recent statistics indicate the majority of those who take the test pass, each year there are those who sit for the test unsuccessfully. Despite this fact, exam failure and tools for dealing with this experience are not often broached in the literature. This essay recalls my experiences with a failed exam attempt and the subsequent emotional turmoil. It also aims to start the conversation regarding the difficulty of coping with the "secret" shame of public, professional failure, and suggests there is room for further discussion and resource development in this area.