Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis

BACKGROUND

Anxiety, obsessive-compulsive, and stress-related disorders frequently co-occur, and patients often present symptoms of several domains. Treatment involves the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), but data on comparative efficacy and acceptability are lacking. We aimed to compare the efficacy of SSRIs, SNRIs, and placebo in multiple symptom domains in patients with these diagnoses over the lifespan through a 3-level network meta-analysis.

METHODS AND FINDINGS

We searched for published and unpublished randomized controlled trials that aimed to assess the efficacy of SSRIs or SNRIs in participants (adults and children) with diagnosis of any anxiety, obsessive-compulsive, or stress-related disorder in MEDLINE, PsycINFO, Embase, and Cochrane Library from inception to 23 April 2015, with an update on 11 November 2020. We supplemented electronic database searches with manual searches for published and unpublished randomized controlled trials registered in publicly accessible clinical trial registries and pharmaceutical companies' databases. No restriction was made regarding comorbidities with any other mental disorder, participants' age and sex, blinding of participants and researchers, date of publication, or study language. The primary outcome was the aggregate measure of internalizing symptoms of these disorders. Secondary outcomes included specific symptom domains and treatment discontinuation rate. We estimated standardized mean differences (SMDs) with 3-level network meta-analysis with random slopes by study for medication and assessment instrument. Risk of bias appraisal was performed using the Cochrane Collaboration's risk of bias tool. This study was registered in PROSPERO (CRD42017069090). We analyzed 469 outcome measures from 135 studies (n = 30,245). All medications were more effective than placebo for the aggregate measure of internalizing symptoms (SMD -0.56, 95% CI -0.62 to -0.51, p < 0.001), for all symptom domains, and in patients from all diagnostic categories. We also found significant results when restricting to the most used assessment instrument for each diagnosis; nevertheless, this restriction led to exclusion of 72.71% of outcome measures. Pairwise comparisons revealed only small differences between medications in efficacy and acceptability. Limitations include the moderate heterogeneity found in most outcomes and the moderate risk of bias identified in most of the trials.

CONCLUSIONS

In this study, we observed that all SSRIs and SNRIs were effective for multiple symptom domains, and in patients from all included diagnostic categories. We found minimal differences between medications concerning efficacy and acceptability. This three-level network meta-analysis contributes to an ongoing discussion about the true benefit of antidepressants with robust evidence, considering the significantly larger quantity of data and higher statistical power when compared to previous studies. The 3-level approach allowed us to properly assess the efficacy of these medications on internalizing psychopathology, avoiding potential biases related to the exclusion of information due to distinct assessment instruments, and to explore the multilevel structure of transdiagnostic efficacy.

Analyzing Indian general public's perspective on anxiety, stress and trauma during Covid-19 - A machine learning study of 840,000 tweets

BACKGROUND AND AIMS

Ever since COVID-19 was declared a pandemic by WHO in late March 2020, more and more people began to share their opinions online about the anxiety, stress, and trauma they suffered because of the pandemic. However, very few studies were conducted to analyze the general public's perception of what causes stress, anxiety, and trauma during COVID-19. This study focuses particularly on understanding Indian citizens.

METHODS

By using Machine learning techniques, particularly Natural language processing, this study focuses on understanding the attitude of Indian citizens while discussing the anxiety, stress, and trauma created because of COVID-19 and the major reasons that cause it. We used Tweets as data for this study. We have used 840,000 tweets for this study.

RESULTS

Our sentiment analysis study revealed the interesting fact that, even while discussing about the stress, anxiety, and trauma caused by COVID-19, most of the tweets were in neutral sentiments. Death and Lockdown caused by the COVID-19 were the two most important aspects that cause stress, anxiety, and Trauma among Indian citizens.

CONCLUSION

It is important for policymakers and health professionals to understand common citizen's perspectives of what causes them stress, anxiety, and trauma to formulate policies and treat the patients. Our study shows that Indian citizens use social media to share their opinions about COVID-19 and as a coping mechanism in unprecedented time.

Large-Scale Functional Brain Network Architecture Changes Associated With Trauma-Related Dissociation

OBJECTIVE

Dissociative experiences commonly occur in response to trauma, and while their presence strongly affects treatment approaches in posttraumatic spectrum disorders, their etiology remains poorly understood and their phenomenology incompletely characterized. Methods to reliably assess the severity of dissociation symptoms, without relying solely on self-report, would have tremendous clinical utility. Brain-based measures have the potential to augment symptom reports, although it remains unclear whether brain-based measures of dissociation are sufficiently sensitive and robust to enable individual-level estimation of dissociation severity based on brain function. The authors sought to test the robustness and sensitivity of a brain-based measure of dissociation severity.

METHODS

An intrinsic network connectivity analysis was applied to functional MRI scans obtained from 65 women with histories of childhood abuse and current posttraumatic stress disorder (PTSD). The authors tested for continuous measures of trauma-related dissociation using the Multidimensional Inventory of Dissociation. Connectivity estimates were derived with a novel machine learning technique using individually defined homologous functional regions for each participant.

RESULTS

The models achieved moderate ability to estimate dissociation, after controlling for childhood trauma and PTSD severity. Connections that contributed the most to the estimation mainly involved the default mode and frontoparietal control networks. By contrast, all models performed at chance levels when using a conventional group-based network parcellation.

CONCLUSIONS

Trauma-related dissociative symptoms, distinct from PTSD and childhood trauma, can be estimated on the basis of network connectivity. Furthermore, between-network brain connectivity may provide an unbiased estimate of symptom severity, paving the way for more objective, clinically useful biomarkers of dissociation and advancing our understanding of its neural mechanisms.

Premature Aging Among Trauma Survivors-The Longitudinal Implications of Sleep Disruptions on Telomere Length and Cognitive Performance

OBJECTIVES

Sleep is necessary for brain function as well as physical and cognitive processes. Sleep disruptions, common with aging, intensify among trauma survivors. Moreover, former prisoners-of-war (ex-POWs) often experience premature aging. This study investigates the longitudinal effects of sleep disruptions for ex-POWs in relation to cognitive performance and telomere length as well as between cognition and telomeres.

METHOD

This study included Israeli veterans from the 1973 Yom Kippur War who participated in four assessments (1991, 2003, 2008, 2015): (a) ex-POWs (n = 99), and (b) veterans who not were captured (controls) (n = 101). Among both groups, sleep disruptions were assessed using a self-report item in all four assessments. Cognitive performance was assessed using the Montreal Cognitive Assessment (MOCA) and telomere length was assessed via total white blood cells (leukocytes) from whole blood samples using Southern blot, both were measured only among ex-POWs in 2015. We conducted descriptive statistics, repeated measures, correlations, and path analyses.

RESULTS

Sleep disruptions were related to lower cognitive performance but not to shorter telomeres. Moreover, cognitive performance and telomere length were found to be related when sleep disruptions were taken into consideration.

CONCLUSION

Interpersonal trauma was shown to be a unique experience resulting in sleep disruptions over time, leading to cognitive impairment. These findings highlight the importance of viewing trauma survivors at high-risk for sleep disruptions. Therefore, it is imperative to inquire about sleep and diagnose cognitive disorders to help identify and treat premature aging.

Trauma Exposure and Mental Health Symptoms in Rural Latinx Adolescents: The Role of Family Processes

Previous research suggests that rural Latinx youth are more likely to experience traumatic events and are at higher risk for developing subsequent psychopathology compared to non-Latinx white youth. The aim of this study is to understand how family processes and values affect risk for internalizing and externalizing symptoms among rural Latinx youth (N = 648, m_age = 15.7 (SD = 1.2)) who are exposed to trauma. Multiple mediation analyses were performed to understand if family variables such as familism and family conflict explain the relationship between trauma exposure and psychopathology. Results suggest that familism partially mediates the relationship between trauma exposure and internalizing and externalizing symptoms, whereas family conflict partially mediates the relationship between trauma exposure and externalizing symptoms. These findings show that family variables are differentially impacted by trauma and have a separate and unique impact on mental health outcomes among rural Latinx youth. Specifically, our findings suggest that familial support or closeness may constitute a nonspecific protective factor for psychopathology among Latinx youth, whereas family conflict creates a stressful home environment that may deter adolescent trauma recovery and lead specifically to externalizing symptoms.

Women's lived experience of well-being in everyday life when living with a stress-related illness

Purpose: The aim of the study was to describe how women with stress-related illness experience well-being in everyday life.Methods: The study was based on a reflective lifeworld research (RLR) approach and the methodological principles of openness, flexibility and bridling. Twelve women, aged 27-54 years, diagnosed with stress-related illness were included. Data were collected with lifeworld interviews based on photographs taken by the women relating to well-being in everyday life. The data were analysed for meaning.Results: Well-being emerged in situations where women could feel an unconditional beingness. This entails not having demands on oneself and includes some form of freedom from having to perform. The surroundings and supportive environments are important for this unconditional beingness to be present. In order to feel well-being in everyday life, the women need to balance their energy and find helpful tools that can achieve a balance in everyday life.Conclusions: Healthcare staff need to understand the importance of unconditional beingness in supportive environments for patients living with stress-related illness in order to support their health and well-being. It is also important to support patients in finding helpful tools that can aid them to achieve a balance in everyday life.

Investigating the Relationship between Trauma Symptoms and Placement Instability

BACKGROUND

Placement stability while in foster care has important implications for children's permanency and well-being. Though a majority of youth have adequate placement stability while in foster care, a substantial minority experience multiple moves during their time in care. Research on correlates of placement instability has demonstrated a relationship between externalizing behaviors and placement instability. Likewise, evidence suggests higher levels of trauma are associated with increased externalizing behaviors. However, few studies have examined the relationship between trauma symptoms and placement instability.

OBJECTIVE

The purpose of this study was to investigate whether children with clinically significant trauma symptoms had higher odds of placement instability.

PARTICIPANTS AND SETTING

Administrative data collected as a part of a summative evaluation for a federally-funded trauma III grant project were used. The sample included 1,668 children ages 5 and older who entered foster care during a 30-month period in a Midwestern state and completed a self-reported trauma screen within 120 days of entering care.

METHODS

Hierarchical logistic regression was conducted to examine the contributions of trauma symptoms scores to placement instability, above and beyond demographic characteristics and case characteristics.

RESULTS

Results from the final analytic model, which controlled for demographic and case characteristics, showed that children with clinically significant trauma symptoms (i.e., scores ≥19) had 46% higher odds of experiencing placement instability (OR = 1.46, 95% CIs [1.16, 1.82], p =  .001). Findings support the need to screen for and treat trauma symptomology among youth in foster care.

Translating Trauma-Informed Principles into Social Work Practice

Trauma-informed social work is characterized by client-centered practices that facilitate trust, safety, respect, collaboration, hope, and shared power. Many agencies have adopted trauma-informed care (TIC) initiatives and many social workers are familiar with its basic principles, but it is challenging to infuse these ideals into real-world service delivery. This article offers 10 trauma-informed practices (TIPs) for translating TIC concepts into action by (a) conceptualizing client problems, strengths, and coping strategies through the trauma lens and (b) responding in ways that avoid inadvertently reinforcing clients' feelings of vulnerability and disempowerment (re-traumatization). TIPs guide workers to consider trauma as an explanation for client problems, incorporate knowledge about trauma into service delivery, understand trauma symptoms, transform trauma narratives, and use the helping relationship as a tool for healing.

A house is not a home: Modeling the effects of social support and connection within resettled refugee populations

AIM

The U.S. resettlement program currently resettles refugees in communities of similar or the same ethnic background known as like-ethnic communities. This practice provides resettled refugees with a familiar community who may be able to provide support through the difficult resettlement process. However, by associating with a like-ethnic community, resettled refugees may limit interaction with the host community, which may have subsequent adverse effects on well-being.

METHODS

This study examined whether satisfaction with community support is moderated by a premigration factor (trauma history) or a postmigration factor (English fluency) in predicting depressive symptoms in a resettled refugee community (N = 179). Four moderation models were analyzed and compared.

RESULTS

The model in which English fluency moderated the relationship between satisfaction with community support and depressive symptoms had the best overall model fit. In addition, trauma history was found to also be a meaningful but secondary moderator within this relationship. English fluency and trauma history within this study did not significantly interact.

CONCLUSION

These results highlight the importance of early English language lessons and community support during resettlement. Further, they emphasize the need to integrate refugees with individuals from similar backgrounds, as well as with host communities throughout resettlement.

Latinx Youth in First Contact with the Justice System: Trauma and Associated Behavioral Health Needs

This study examines the prevalence of trauma exposure and its association with psychiatric symptoms, substance use, and sexual activity among First-Time Offending, Court-Involved Non-Incarcerated (FTO-CINI) Latinx youth. Latinx youth (N = 181), ages 12-18, were recruited from a family court in the Northeastern region of the United States as part of a longitudinal cohort study of 423 FTO-CINI youth. Baseline data on trauma exposure and symptoms, psychiatric symptoms, substance use (alcohol/marijuana), and sexual activity among the Latinx sample were analyzed by age, gender, and offense type (status versus delinquent). Almost three-quarters of Latinx FTO-CINI youth reported lifetime trauma exposure. Almost half of Latinx youth reported lifetime marijuana use, 30% reported lifetime alcohol use, and 33% reported lifetime sexual activity. Females reported higher rates of internalizing symptoms and greater affect dysregulation. Trauma-exposed youth were more likely than their non-exposed peers to have reported more externalizing symptoms; trauma-exposed females compared to trauma-exposed males reported more severe internalizing symptoms. Latinx FTO-CINI females may have different behavioral health needs than their male counterparts. Court-based screening and assessment practices should attend to the specific behavioral needs of this unique, underserved population.

Achieving Service Change Through the Implementation of a Trauma-Informed Care Training Program Within a Mental Health Service

As evidence continues to accumulate for the association between childhood trauma and long-term adverse outcomes, Trauma-Informed Care (TIC) approaches are emerging as fundamental to contemporary mental health services. To evaluate a workshop designed to influence mental health practitioners in TIC principles and practices. Nursing, medical and allied health professionals completed pre and post measures of confidence, awareness and attitudes towards TIC practice. The workshop was rated as highly relevant and useful to clinician's practice. Participants' self-reported confidence, awareness and attitudes towards TIC significantly increased (p < .001) and the perceived number of barriers to working within a TIC framework significantly decreased (p < .05). Child and Adolescent Mental Health clinicians routinely screened for trauma and 80% had received training in a trauma specific intervention at follow-up. This brief training provides an important foundation for the development of trauma-informed, evidence-based mental health services.

[Toward cultural assessment of grief and grief-related psychopathology]

Ways of dealing with bereavement and grief are influenced by the norms of one's cultural identity. Cultural assessment of bereavement and grief is therefore needed for a comprehensive evaluation of grief-related psychopathology and for negotiating appropriate treatment. Cultural aspects of bereavement and grief include cultural traditions related to death, bereavement, and mourning as well as help seeking and coping. To facilitate clinical exploration of cultural aspects of bereavement and grief, the authors propose a set of brief, person-centered, and open-ended questions as a draft supplementary module to the DSM-5 Cultural Formulation Interview. Three case vignettes show how cultural assessment of bereavement and grief may contribute to diagnosis, treatment, and enhancing rapport in patients who seek help following the loss of loved ones.

Do adverse life events at first onset of auditory verbal hallucinations influence subsequent voice characteristics? Results from an epidemiological study

Understanding what happens at first onset of auditory verbal hallucinations (AVHs) is extremely important on a clinical and theoretical level. Previous studies have only focused on age with regard to first onset of AVHs. In the current epidemiological study, we examined a number of aspects relating to first onset of AVHs, such as the role of adverse life events at first onset of AVHs on symptom severity and general mental health. For this purpose, we compared participants who reported adverse life events at first onset of AHVs (adverse-trigger group; N = 76) to those that did not report any specific events at first onset of AVHs (no-adverse-trigger group; N = 59) on a large array of variables. Results showed that AVHs in the adverse-trigger group were experienced as more emotional compared to the no-adverse-trigger group. In addition, the adverse-trigger group more often reported hallucinations in other (non-auditory) sensory modalities (e.g. visual) compared to the no-adverse-trigger group. Furthermore, the adverse-trigger group reported poorer general mental health, reported having contact with mental health professionals more often, and also reported more frequently taking medication for psychological problems in general. The implications of these findings are discussed.

Posttraumatic Stress Disorder Symptom Clusters and Acquired Capability for Suicide: A Reexamination Using DSM-5 Criteria

This study used the interpersonal-psychological theory of suicide to explore the relationships among DSM-5 posttraumatic stress disorder (PTSD) symptom clusters derived from the six-factor anhedonia model and facets of acquired capability for suicide (ACS). In a sample of 373 trauma-exposed undergraduates, most PTSD symptom clusters were negatively associated with facets of ACS in bivariate correlations, but the anhedonia cluster was positively associated with ACS in regression models. Structure coefficients and commonality analysis indicated that anhedonia served as a suppressor variable for the other symptom clusters. Our findings further elucidate the complex relationship between specific PTSD symptom clusters and ACS.

A Calming Cushion as a Therapeutic Wellness Tool for Youths with Disabilities and History of Trauma

Seclusion and restraint are commonly used by residential staff to control unsafe behaviors of youths with disabilities and complex trauma histories. This pilot study examined the effect of a nonrestraining cushion as a calming device and wellness tool in a setting that prohibits supportive physical contact, to see to what extent the cushion might help these youths to better regulate their emotional distress and unwanted behaviors. Volunteers used the cushion for 15 minutes over 24 sessions. Nine students completed the study and reported reduction in anxiety and agitation, and a soothing feeling with residual effects to their daily routines. This pilot study suggests that the use of a nonrestraining, deep-pressure cushion may simulate a secure holding effect for young people with emotional dysregulation. The cushion is a safe and healing wellness tool that empowers youths and provides programs with an alternative to seclusion and restraint.

Forensic implications of changes in DSM-5 criteria for responses to trauma and stress

DSM-5 significantly changed the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) relative to DSM-IV/DSM-IV-TR. These changes do not alter its basic approach to diagnosing mental disorders, which treats each disorder as a separate category. This article analyzes the strengths and weaknesses of the categorical approach, and reviews empirical evidence regarding the impact of changes within it on the ease or difficulty of receiving the PTSD diagnosis. It especially analyzes the impact of newly included symptoms that are meant to identify cases in which trauma exposure was associated with changes in more serious PTSD cases, known as Complex PTSD (C-PTSD). It proposes some effects that the changes could have on psychological injury claims. Many changes could support plaintiffs' claims while others could support defense claims. Some changes could support either. Overall, DSM-5 PTSD diagnosis is more responsive to individual differences in symptom presentations and appears able to diagnose some C-PTSD cases. The thesis throughout the article is that PTSD diagnostic accuracy could be improved further, especially for C-PTSD cases, by complementing its current exclusive reliance on behavioral symptoms that are characteristic of victims in general with assessment of the meaning that the symptoms have for individual victims. The article proposes some principles to guide interpretation of the individualized meaning of victims' symptoms, which help make the reasoning behind the interpretations explicit.

Attachment-Based Family Therapy: A Review of the Empirical Support

Attachment-based family therapy (ABFT) is an empirically supported treatment designed to capitalize on the innate, biological desire for meaningful and secure relationships. The therapy is grounded in attachment theory and provides an interpersonal, process-oriented, trauma-focused approach to treating adolescent depression, suicidality, and trauma. Although a process-oriented therapy, ABFT offers a clear structure and road map to help therapists quickly address attachment ruptures that lie at the core of family conflict. Several clinical trials and process studies have demonstrated empirical support for the model and its proposed mechanism of change. This article provides an overview of the clinical model and the existing empirical support for ABFT.

Switch Function and Pathological Dissociation in Acute Psychiatric Inpatients

Swift switching, along with atypical ability on updating and inhibition, has been found in non-clinical dissociators. However, whether swift switching is a cognitive endophenotype that intertwines with traumatisation and pathological dissociation remains unknown. Unspecified acute psychiatric patients were recruited to verify a hypothesis that pathological dissociation is associated with swift switching and traumatisation may explain this relationship. Behavioural measures of intellectual function and three executive functions including updating, switching and inhibition were administered, together with standardised scales to evaluate pathological dissociation and traumatisation. Our results showed superior control ability on switching and updating in inpatients who displayed more symptoms of pathological dissociation. When all three executive functions were entered as predictors, in addition to intellectual quotient and demographic variables to regress upon pathological dissociation, switching rather than updating remained the significant predictor. Importantly, the relationship between pathological dissociation and switching became non-significant when the effect of childhood trauma were controlled. The results support a trauma-related switching hypothesis which postulates swift switching as a cognitive endophenotype of pathological dissociation; traumatisation in childhood may explain the importance of swift switching.

Examining the role of personal traumas in a nurse's work life

In this monthly column, Aysha Mendes discusses the impact a nurse's personal traumas can have on his or her nursing practice, professional and personal experience of caring, and on patients and their families.

Clergy Stress through Working with Trauma: A Qualitative Study of Secondary Impact

This article explores the impact upon clergy as a result of working with trauma within their pastoral ministry. The paper is unusual in that examines the toll exacted as part of their daily pastoral ministry in offering care and support to those who have encountered life's daily tragedies. Utilizing a sample of 16 serving Irish clergy Drawing on an Interpretative Phenomenological Analysis framework the data was organized into super-ordinate themes. Findings indicate that this is a challenging aspect of the ministry and one that can result in physical, cognitive and behavioural effects not only on those who provide the initial support but also in turn upon their informal support networks.

The Use of Traumatic Biblical Narratives in Spiritual Recovery from Trauma: Theory and Case Study

Scholars in different disciplines have begun to converge in their answer to the fundamental question, "what does it mean to be a unique person." Writers in the fields of psychology, neurology and theology have begun to address the fact that identity is tied to the narratives we create, more than the events that occur in life. Traumatic events in life can create discontinuities in that narrative that interfere with functioning. In this essay, I propose the use of traumatic Biblical narratives in pastoral counseling to assist the client in articulating personal traumatic episodes and beginning the process of integrating traumatic experiences and initiating growth.