Religion Might Keep Anxiety at Bay

For many, religious activity changes between childhood and adulthood, and a new study finds this could affect one’s mental health.

According to Temple University’s Joanna Maselko, women who had stopped being religiously active were more than three times more likely to have suffered generalized anxiety and alcohol abuse/dependence than women who reported always having been active.

“One’s lifetime pattern of religious service attendance can be related to psychiatric illness,” says Maselko, an assistant professor of public health and co-author of the study, which appears in the January issue of Social Psychiatry and Psychiatric Epidemiology.

Conversely, men who stopped being religiously active were less likely to suffer major depression when compared to men who had always been religiously active.

Maselko offers one possible explanation for the gender differences in the relationship between religious activity and mental health.

“Women are simply more integrated into the social networks of their religious communities. When they stop attending religious services, they lose access to that network and all its potential benefits. Men may not be as integrated into the religious community in the first place and so may not suffer the negative consequences of leaving,” Maselko says.

The study expands on previous research in the field by analyzing the relationship between mental health — anxiety, depression and alcohol dependence or abuse — and spirituality using current and past levels, said Maselko, who conducted the research when she was at Harvard University.

In the study sample, comprising 718 adults, a majority of men and women changed their level of religious activity between childhood and adulthood, which was critical information for the researchers.

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Patients with Depression Seeing Primary Care Physicians Frequently Don't Receive High Quality Care

Most patients with depression who are treated by primary care physicians do not receive care consistent with quality standards, according to a new RAND Corporation study.

Physicians had high rates of adherence to just one-third of the 20 measures of quality that researchers examined and had low rates of adherence to nearly half of the treatment recommendations studied, according to the report in the Sept. 4 edition of the Annals of Internal Medicine.

“These findings are important for patients since most cases of depression are diagnosed and treated in primary care settings,” says senior author Dr. Lisa Rubenstein, the study's senior author, and a senior scientist at RAND, a nonprofit research organization, and a physician at the Veterans Affairs Greater Los Angeles Healthcare System. “This shows that additional efforts are needed to improve the treatment of depression.”

The study also found that patients who received better-quality care reported fewer symptoms of depression up to two years after the start of treatment. The findings are among the first linking quality guidelines for depression treatment with improved patient outcomes in community settings.

“These are initial findings, but they suggest that programs that encourage doctors to follow treatment guidelines can help improve the long-term outlook for people with depression,” says Rubenstein, who also is affiliated with the David Geffen School of Medicine at UCLA.

Previous studies have shown that primary care providers do a poor job following guidelines for antidepressant use or psychotherapy. The RAND study is one of the first to assess primary care providers' adherence to a comprehensive set of treatment guidelines for depression.

Researchers from RAND Health examined the experiences of health care providers and patients who took part from 1996 to 1998 in the Quality Improvement for Depression collaboration, which was designed to encourage primary care providers to adopt comprehensive depression treatment guidelines developed by the U.S. Agency for Healthcare Research and Quality.

The RAND study examined the experiences of 1,131 patients with depression who were treated in 45 primary care practices across 13 states. Study sites ranged from small private practices to large managed care organizations. About 10 percent of patients in the study were from Veterans Affairs practices.

Researchers examined whether physicians and other health providers followed 20 different measures of quality, as well as analyzing patients' reports about the status of their depression at 12, 18 and 24 months after starting treatment.

The study found that most primary care physicians did a good job of diagnosing and beginning treatment for depression, with guidelines aimed at these issues followed more than 70 percent of the time. These guidelines includes items such as talking to patients about depression and closely monitoring patients newly placed on antidepressant medication.

But researchers found that primary care clinicians did less well following up with treatment over time. Fewer than half of the patients in the study completed the minimal course of treatment for either antidepressant drugs or psychotherapy, and only slightly more than half the depressed patients who were not treated were monitored closely.

The lowest quality of care occurred among the patients who exhibited the most serious symptoms, including patients who showed evidence of suicide or substance abuse. For example, among patients who had a previous suicide attempt, just 35 percent were referred to a mental health specialist over the next six months.

“Primary care physicians were good at diagnosing depression, but they did not do as good a good job of managing the sickest patients,” Rubenstein says. “Right now, primary care physicians don't have the tools necessary to decide which patients to treat and which to refer on to specialized mental health care.”

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Faster-acting Antidepressants Closer to Becoming Reality

A new study has revealed more about how the medication ketamine, when used experimentally for depression, relieves symptoms of the disorder in hours instead of the weeks or months it takes for current antidepressants to work. While ketamine itself probably won’t come into use as an antidepressant because of its side effects, the new finding moves scientists considerably closer to understanding how to develop faster-acting antidepressant medications – among the priorities of the National Institute of Mental Health (NIMH), part of the National Institutes of Health.

Ketamine blocks a receptor called NMDA on brain cells, an earlier NIMH study in humans had shown, but the new study in mice shows that this is an intermediate step. It turns out that blocking NMDA increases the activity of another receptor, AMPA, and that this boost in AMPA is crucial for ketamine’s rapid antidepressant actions. The study was reported online in Biological Psychiatry on July 23, by NIMH researchers Husseini K. Manji, MD, Guang Chen, MD, PhD, Carlos Zarate, MD, and colleagues.

“Our research is showing us how to develop medications that get at the biological roots of depression. This new finding is a major step toward learning how to improve treatment for the millions of Americans with this debilitating disorder; toward eliminating the weeks of suffering and uncertainty they have to endure while they wait for their medications to work,” says NIH Director Elias Zerhouni, M.D.

Almost 15 million American adults have a depressive disorder. During the long wait to begin feeling the effects of conventional medications, patients may worsen, raising the risk of suicide for some. Depressive disorders also affect children and adolescents.

By aiming new medications at more direct molecular targets, such as NMDA or AMPA, scientists may be able to bypass some of the steps through which current antidepressants indirectly exert their effects – a roundabout route that accounts for the long time it takes for patients to begin feeling better with the conventional medications.

While ketamine appears to achieve this, it is an unlikely candidate to become a new treatment for depression, because of the side effects it can cause in humans, including hallucinations. It is approved as an anesthetic by the Food and Drug Administration at much higher doses than those given in the study, but its use is limited because it may cause hallucinations during recovery from anesthesia.

Both NMDA and AMPA are receptors for the neurotransmitter glutamate, one of the chemical messengers that enable brain cells to communicate with each other. The glutamate system has been implicated in depression recently, leading to efforts to unravel its molecular machinery in search of abnormalities and of better targets for antidepressant medications.

This focus on the glutamate system is a departure from the thinking that led to currently available antidepressants, which are thought to relieve depression through a lengthy trickle-down process of biochemical reactions that affect the circuitry underlying depression.

The fact that NMDA and AMPA receptors are part of the glutamate system and that targeting them directly led to such rapid, sustained relief of depression-like behaviors in this study – and that a single dose of ketamine did the same in humans in the earlier study – suggests that they are probably the key targets for antidepressant medications.

“In any other illness of depression’s magnitude, patients aren’t expected to just accept that their treatments won’t start helping them for weeks or months. The value of our research on compounds like ketamine is that it tells us where to look for more precise targets for new kinds of medications that can close the gap,” says NIMH Director Thomas Insel, MD. “We’re making tremendous progress.”

To conduct the new study, researchers induced depression-like behaviors in mice; for example, the mice gave up after being forced to engage in hopeless tasks, such as prolonged swimming. A dose of ketamine reversed the depression-like behaviors for at least two weeks.

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Early Behavior Problems Appear to Lead to Peer Rejection, Friendlessness

Behavior problems in the early grades appear to lead to peer rejection and a lack of friends in elementary school. This, in turn, can lead to early adolescent depression and loneliness.

Those are the findings of a new study by researchers at the Universities of Montreal and Oslo; the study is published in the July/August 2007 issue of the journal Child Development.

Researchers collected information from 551 children beginning when the children were 6 years old and continuing annually until they were 13. They also collected information from the children’s teachers, mothers, and peers.

Specifically, teachers and mothers described the children’s levels of anxiety (including a tendency to prefer solitary play and to fear new situations) and their disruptiveness (including physical aggression and hyperactivity) when the children were 6 and 7. Classroom peers reported on the children they liked most and least each year from ages 8 to 11. Children reported how many friends they had each year from ages 8 to 11, as well as their own levels of depression, loneliness, and involvement with delinquent behaviors at ages 12 and 13.

The researchers found that children who were disruptive in early childhood were more likely to be rejected and lack friends in elementary school. Anxious children also tended to have few friends, although they were not more likely to be rejected by their peers.

The study also found that rejection contributes to the risk that children won’t have friends. Children who are rejected early in elementary school are more likely to lack friends later in elementary school.

Both rejection and a lack of friends in elementary school put children at risk for adjustment problems in adolescence, the researchers found. Specifically, children who are rejected in elementary school are more likely to be lonely as adolescents, while children who lack friends in the early grades—a critical time for the development of close, reciprocal relationships—are more likely to be lonely and depressed as teenagers. In contrast, rejection and a lack of friends don’t put children at risk for delinquency—only early disruptiveness does that.

“The study’s findings indicate that the developmental consequences of risky peer relations are not limited to childhood,” according to Sara Pedersen, a postdoctoral fellow at the University of Montreal’s Research Unit on Children’s Psychosocial Maladjustment and lead author of the study. “These results suggest that interventions to prevent adolescent depression and loneliness should target elementary school peer relationships. The results also reveal that interventions targeting only childhood rejection and friendlessness are unlikely to prevent later delinquency.”

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Adding Folic Acid to Bread Could Help Fight Against Depression

A unique study by researchers at the University of York and Hull York Medical School has confirmed a link between depression and low levels of folate, a vitamin which comes from vegetables.

In research published in the July edition of the Journal of Epidemiology and Community Health, the York team led by Dr Simon Gilbody, concluded that there was a link between depression and low folate levels, following a review of 11 previous studies involving 15,315 participants.

Last month, the UK Food Standards Agency recommended to UK Health Ministers the introduction of mandatory fortification of either bread or flour with folic acid to prevent neural tube defects, which can result in miscarriage, neonatal death or lifelong disability. The York study suggests that the measure may also help in the fight against depression.

Dr Gilbody says: "Our study is unique in that for the first time all the relevant evidence in this controversial area has been brought together. Although the research does not prove that low folate causes depression, we can now be sure that the two are linked. Interestingly, there is also some trial evidence that suggests folic acid supplements can benefit people with depression. We recommend that large trials should be carried out to further test this suggestion."

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Suicide Attempts Decline After Depression Treatment

In a study of more than 100,000 patients treated for depression, suicide attempts declined during the first month of treatment—whether that treatment consisted of medication, psychotherapy, or both. The findings, published by Group Health researchers in the July American Journal of Psychiatry, show a similar pattern for populations of adolescents and young adults (up to age 24) as for older adults.

The study sheds new light on the “black box” advisory that the U.S. Food and Drug Administration (FDA) placed in 2004 and has revised since then, said Greg Simon, MD, MPH, the Group Health psychiatrist who led the study. The advisory—which has concerned many patients, families, and care providers—warns that suicidal behavior may emerge soon after people younger than 25 start treatment with newer antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). It was spurred by randomized placebo-controlled trials showing that starting to take an SSRI can make thoughts of suicide more common among some teens and young adults.

Dr. Simon’s study is the first published research to compare the risk of suicide attempts before and after the start of treatment with not only antidepressants but also psychotherapy. It is based on computerized medical and pharmacy records for more than 109,000 patients who started treatment for depression at Group Health from 1996 to 2005.

In the study, suicide attempts were about twice as common among patients up to age 24 as among older adults. However, the time pattern was the same for both age groups, regardless of the type of treatment they received: Suicide attempts were most likely during the month before treatment started, falling by at least 50 percent in the month after treatment began, with steady declines thereafter.

At all time points—up to three months before and six months after starting treatment—patients who received their antidepressant prescription from a psychiatrist tended to be most likely to attempt suicide. Those who received it from their primary care doctor were least likely to attempt suicide, with levels in between for those who got individual psychotherapy from a therapist other than a psychiatrist. “That’s not because seeing a psychiatrist makes you want to kill yourself,” says Dr. Simon. Rather, he suggests, these results reflect the fact that people with severe depression, who tend to be more suicidal, are more likely to be referred to psychiatrists, while those with milder depression stick with their primary doctors.

“Our study indicates that there’s nothing specific to antidepressant medications that would either make large populations of people with depression start trying to kill themselves—or protect them from suicidal thoughts,” says Dr. Simon. “Instead, we think that, on average, starting any type of treatment—medication, psychotherapy, or both—helps most people of any age have fewer symptoms of depression, including thinking about suicide and attempting it.” That said, he likened population-based studies—both observational studies such as this one and randomized controlled trials of medications—to “circumstantial evidence” about what happens to individual patients.

Like other psychiatrists, Dr. Simon has seen a few depressed patients start having suicidal thoughts while taking antidepressant medication despite never having thought about suicide before then. He hypothesizes that subgroups of people may be vulnerable to becoming more agitated or suicidal after taking these drugs. “We hope to learn how to identify these people in advance,” he says.

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Developmental, Behavioral Problems May Plague Kids With Asthma

Much of the research surrounding childhood asthma has sought new approaches to managing the disease. However, little was done to address other conditions that often appear along with asthma including depression and Attention Deficit Hyperactivity Disorder (ADHD), which can negatively affect a child's ability to cope.

Research completed at the University of Virginia Children's Hospital asserts that until these extra conditions or "co-morbidities" are addressed, asthma education programs will not be able to help young patients to the fullest. The results will be published in the April 12 issue of The Journal of Developmental and Behavioral Pediatrics.

"We can definitively state that families with asthmatic children not only report higher incidences of ADHD, but also of depression, anxiety and learning disabilities," says Dr. James Blackman, developmental pediatrician at the Kluge Children's Rehabilitation Center at UVa Children's Hospital and lead study author. "If we can manage these co-morbidities, we can better help children with asthma and their families to manage the disease in the healthiest way possible."

Data for the research came from the National Survey of Children's Health 2003, which was obtained from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics. The survey results came from telephone polls of households with children. Parents who reported that their child had asthma also were asked to report the severity of their children's asthma and any behavior problems. Information was gathered on a total of 102,353 children from ages 0-17 years during 2003-2004. The survey results were analyzed using SUDAAN, specialized software for analyzing clustered data.

The study uncovered depression, anxiety, behavioral problems, and learning disabilities as co-morbidities common among children with asthma. The more severe the child's asthma was, the higher the incidence of these types of problems. More than 10 percent of asthmatic children experienced problems that lasted longer than a year and required counseling or treatment.

What's more, these children often missed ten or more days of school, leading parents and caregivers to worry about their children's healthy academic and emotional development.

"What also is important about this research is that it shows how asthma can lead to psychosocial disadvantages for children in our society," adds Blackman.

While the medical and research establishment should continue to address the societal problems of poverty and poor education, Blackman believes that children with asthma need to receive tailored and precise treatments addressing their physical and mental and developmental health. This could lead to fewer missed days in school and fewer calls home to parents for behavioral and academic problems.


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Depressed Mothers Can Still Be Good Moms

Medically treating post-partum depression may not be enough to improve a mother’s relationship with her baby, and is only part of the equation, according to a new study done in part by the University of Alberta.

The other essential factor is giving struggling new mothers basic tools to read behavioural cues from their babies and effectively respond to their needs, says Robert Short, a co-author on the study and professor of educational psychology at the University of Alberta in Edmonton, Canada.

The pilot study of 11 mild to moderately depressed mothers and their babies showed that when the women were taught how to react to their babies’ emotional cues, the infants responded with heightened levels of interest and joy, even though their mothers’ depression levels did not change.

"They were able to be positive for their babies despite their own struggles," Short says.

The study, which also included research from the University of New Brunswick, appears in this month’s issue of Journal of Affective Disorders.

The study used an intervention program called the Keys to Caregiving (KTC) that helps parents understand and respond to infant behaviours, with the goal of increasing positive expressions in the babies. Over five weekly group sessions, the moms and babies were videotaped before and after KTC intervention. The tapes were then scored for the facial emotion expressions of the infants. In one experiment, prior to intervention, 39 percent of infants displayed interest in their mothers’ expressions; afterwards, it rose to 67 percent. The babies’ expressions of joy rose from 2.8 percent to 13 percent.

The interventions consisted of educating the mothers about different infant states (levels of sleeping and waking), behaviours (unique personalities), cues (non-verbal language) and interaction during feedings. The mothers then practiced these new skills during training sessions and at home. "This gives depressed mothers some sort of structure in terms of what the baby is doing. It doesn’t focus on her condition, but on what she can do and how she can better interpret her baby."

Three to 30 percent of new mothers suffer post-partum depression, which can result in serious growth and developmental problems for infants, Short says. "What this study shows is that if you focus medically just on the mother’s condition, it doesn’t necessarily follow that it will improve the type of interactions that are essential for normal healthy child development."

Programs like KTC should apply to all new mothers, he adds.

"We assume that mothers have this automatic ability to interact with their babies, and not all of them do," Short notes.

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