Classroom-Based Strategies to Reduce Disparities in Physical Activity Among Children with Asthma.

Children with asthma often experience physical activity (PA) induced symptoms 5-15 min following the start of exercise. Classroom PA breaks provide short intermittent bouts of PA and may represent a novel strategy to safely promote PA participation in this clinical population. The purpose of this study was to determine the feasibility of a classroom-based PA intervention, Interrupting Prolonged Sitting with Activity (InPACT), where teachers implement 5 × 4-min moderate-to-vigorous physical activity (MVPA) breaks throughout the school day. Nine classrooms at one elementary-middle school in Detroit, MI (student demographics: 79% Hispanic; 80% on free/reduced lunch; 31% prevalence of asthma and asthma-like symptoms) participated in this 20-week intervention. Asthma status was self-reported via the International Study of Asthma and Allergies in Childhood (ISAAC) Video Questionnaire in conjunction with nurse documentation. PA participation, exercise intensity, and asthmatic symptom occurrence were assessed via direct observation. Students accumulated approximately 17 min of activity per day during PA breaks. Compared to students without asthma, a higher percentage of students with asthma participated in MVPA (asthma: 52.9% ± 1.2%; non-asthma: 46.2% ± 0.8%; p = 0.01), a lower percentage participated in light PA (asthma: 25.9% ± 1.0%; non-asthma: 30.1% ± 0.7%; p = 0.01), and sedentary time during activity breaks (asthma: 21.2% ± 0.9%; non-asthma: 23.8% ± 0.7%; p = 0.02). Out of 294 observations, six instances of asthmatic symptoms (coughing) were observed in students with asthma 5-15 min following the PA break. Symptoms self-resolved within 15-min of the PA break and did not result in sustained exercise-induced bronchoconstriction. Classroom-based interventions that incorporate short intermittent bouts of PA represent safe exercises for children with asthma and may help to reduce PA disparities in this clinical population.

Associations between Self-Reported Daily Affect Ratings and Sleep Duration during the First Two Weeks of Antidepressant Therapy.

Background: In the context of a randomized controlled trial evaluating the efficacy of augmenting fluoxetine treatment in young adults with major depressive disorder (MDD) using a modified repeated partial sleep deprivation protocol contrasting 2 weeks of restricted time in bed (i.e., 6 h TIB) to no time in bed restriction (i.e., 8 h TIB) the study examines whether sleep duration and the timing of repeated partial sleep deprivation predicts patient-reported affect ratings. Participants: Participants included 58 young adults with DSM-IV-diagnosed MDD. Methods: Daily ratings of affect and sleep were collected during the first 2 weeks of initiating fluoxetine treatment, yielding 630 person-days. Actigraphy monitoring was employed to assess compliance with time in bed condition. Results: Negative affect ratings and positivity ratios in the morning were more improved among participants assigned to the 6 h TIB condition compared to the 8 h TIB group. Participants whose bedtime was delayed by 2-h nightly demonstrated the most significant improvement in negative affect and positivity ratio during the first 2 weeks of fluoxetine therapy. Moreover, the trajectory of morning negative affect ratings in the first 2 weeks was predictive of remission after 4 weeks of fluoxetine therapy. Conclusions: These findings suggest that monitoring changes in daily affect may be a valuable marker of early treatment response in young adults with MDD.

Association between asthma, obesity, and health behaviors in African American youth.

Background: There is a clear relationship between obesity and asthma, with obesity recognized as a risk factor for asthma. There is mounting evidence, however, that asthma may predict obesity risk via behavioral pathways. Objectives: The purpose of this study was to assess the cross-sectional relationships between asthma, body mass index (BMI) percentile, and behavioral factors including caloric intake, dietary inflammatory index, moderate-vigorous physical activity (MVPA), and sedentary time (SED) among African American adolescents. Methods: A community-based sample of 195 African American youth (ages 11-18 years) were included in this analysis. Asthma status was based on self-report using the International Study of Asthma and Allergies in Children's Phase Three questionnaire. MVPA and SED were measured via accelerometry, and caloric intake and dietary inflammatory index were evaluated with the Food Frequency Questionnaire. Weight status was assessed via BMI percentile using measured weight, height, and CDC growth charts. Results: Adolescents with a history of asthma were significantly more overweight (62% vs. 43%, p = 0.04) and consumed a higher inflammatory diet (1.6 ± 0.3 vs. 1.0 ± 0.2, p = 0.02) than their peers who never had asthma. After adjusting for all covariates, activity and dietary variables, odds ratio analysis revealed adolescents who reported ever having asthma were 3.1 ± 1.5 times as likely to be overweight or obese than adolescents with no asthma history (p = 0.02). Conclusions: Presence of asthma history was associated with increased obesity risk in African American adolescents, independent of behavioral factors. Longitudinal studies are needed to better understand the relationship between asthma and obesity in African American adolescents.

The Michigan Child Collaborative Care Program: Building a Telepsychiatry Consultation Service.

This column describes the establishment of the Michigan Child Collaborative Care (MC3), a statewide telepsychiatry consultation program that provides support to primary care providers (PCPs) in meeting the mental health needs of youths and perinatal women. The MC3 program provides cost-effective, timely, remote consultation to primary care providers in an effort to address the lack of access and scarcity of resources in child, adolescent, and perinatal psychiatry. Data from 10,445 service requests are summarized. Common diagnoses included attention-deficit hyperactivity disorder, mood disorders, anxiety disorders, and autistic spectrum disorders, with many cases (58%) deemed moderate to severe. Co-occurring psychological trauma was suspected in 9% of service requests. Partnerships, stakeholder roles, PCP engagement, and workflow integration are highlighted as keys to the program's success.

Modified Cognitive Behavioral Therapy for Insomnia in Depressed Adolescents: A Pilot Study.

Objective/Background: The purpose of the study was to pilot a five-week insomnia treatment in adolescents with major depressive disorder (MDD) and insomnia. This was an open-label trial of a modified-group cognitive behavioral therapy for insomnia (CBTI). Participants: Adolescents with MDD (n = 16; mean age = 17.3 +/- 1.7), characterized by the Children's Depression Rating Scale-Revised T-score ≥ 55 and insomnia, characterized by > 30 min to fall or return to sleep and an Insomnia Severity Index (ISI) score of ≥ 7 participated. Methods: Sleep diaries, actigraphy, weekly ISI, Quick Inventory of Depressive Symptomatology (QIDS), and Multidimensional Fatigue Inventory (MFI) were completed. Results: Paired t-tests comparing pre- and posttreatment revealed a decrease in sleep onset latency from 41 min +/- 14 min to 18 min +/- 8.9 min (t = 5.9, p = .004). Linear mixed modeling across sessions revealed that ISI (B = 11.0, SE = 0.94, p < .001), QIDS (B = 11.3, SE = 0.96, p < .001), and MFI (B = 30.0, SE = 4.4, p < .001) improved across treatment. Daily sleep diaries showed decreased wake during the night (B = 22.8, SE = 7.19, p = .008), increased sleep time (B = 382.4, SE = 71.89, p < .001), and increased quality of sleep (B = 3.7, SE = 0.37, p < .001). When asked whether group members would recommend this group, 27% responded "yes" and 73% responded "definitely yes." Conclusions: Additional controlled studies utilizing sleep-focused therapy in depressed adolescents with insomnia are warranted.

Insomnia as a Moderator of Response to Time in Bed Restriction for Augmenting Antidepressant Treatment: A Preliminary Investigation.

BACKGROUND: There are complex, bidirectional associations between major depressive disorder and insomnia. In the present study, we evaluated insomnia as a moderator of response to antidepressant therapy in the context of a sleep manipulation (time in bed restriction) for major depressive disorder. METHODS: Fifty-eight adults with major depressive disorder received 8 weeks of fluoxetine 20-40 mgs and were randomized to 8 hr time in bed (8h TIB) or 6 hr time in bed (6h TIB) for the first 2 weeks (participants in the 6h TIB condition were further randomized to a delayed bedtime (Late Bedtime) or advanced rise time (Early Rise Time) group). Insomnia was assessed at baseline using the Insomnia Severity Index. Depression symptom severity was determined by the clinician-rated 17-item Hamilton Rating Scale for Depression (HAMD-17), completed weekly. RESULTS: A group by time interaction was observed whereby HAMD-17 scores were higher for participants assigned to the 6h TIB group (without insomnia, weeks 3 through 7; with insomnia from week 3 through 6, ps < .05) relative to participants without insomnia assigned to the 8h TIB group. There were no differences in HAMD-17 scores for participants with insomnia in the 6h TIB group relative to the 8h TIB group. CONCLUSION: These preliminary findings suggest that response to fluoxetine may be hindered by TIB restriction in individuals without insomnia. Individuals with insomnia respond similarly to fluoxetine regardless of whether their TIB is restricted. Limitations include exclusive use of self-report measures to categorize insomnia, and small sample sizes in several of the subgroups.

Moving Towards Wellness: Physical activity practices, perspectives, and preferences of users of outpatient mental health service.

OBJECTIVE: This study assessed the beliefs, barriers and preferences for physical activity (PA) among users of outpatient mental health (MH) services. Outpatient discussions with MH providers were also evaluated. METHOD: Between September-December 2014, patient advisors approached adult and family members in an academic MH clinic's waiting room on high volume patient visit days during peak clinic hours; 83% participated in the survey. Analyses were restricted to MH services users (n=295). RESULTS: Fully 84% of respondents reported a link between PA and their mood or anxiety level and 85% wanted to be more active. Less than half currently met US PA guidelines (≥150min/week). Most (52%) reported their mood limited their involvement in PA. Only 37% reported their MH providers regularly discussed PA with them. Beliefs about the benefits of physical activity (p<0.0001), mood limiting their ability to be physically active (p=0.03), and wanting to be more physically active (p=0.02) were significant predictors of PA (min/week) in the multivariate linear regression model. CONCLUSIONS: Most MH outpatients may need and want assistance in increasing PA. Patient-centered research could inform the development of PA programs in MH settings.

Relationships between circadian measures, depression, and response to antidepressant treatment: A preliminary investigation.

Few studies have examined relationships between circadian rhythms and unipolar major depressive disorder. Further, no study to date has examined circadian markers as predictors of response to depression treatment. In the present study, we examined associations between circadian timing and its alignment with sleep and depression severity in 30 adults with major depressive disorder who completed a randomized controlled trial of two weeks of time in bed (TIB) restriction administered adjunctive to fluoxetine, with a focus on sex differences. Thirty adults with major depressive disorder received 8 weeks of fluoxetine 20-40 mgs and were randomized to 8h TIB or 6h TIB for the first 2 weeks. Participants in the 6h TIB condition were further randomized to a delayed bedtime or advanced risetime group. Circadian measures included dim light melatonin onset (DLMO) and the difference between DLMO and midsleep point (i.e., phase angle difference). Depression was assessed using the Hamilton Rating Scale for Depression. For females, a phase delay after 2 weeks of fluoxetine and the experimental TIB manipulation was associated with a poorer response to fluoxetine, and depression severity was negatively correlated with phase angle difference, whereas males showed a positive correlation between depression severity and phase angle difference.

Effects of Restricted Time in Bed on Antidepressant Treatment Response: A Randomized Controlled Trial.

OBJECTIVE: Antidepressant response onset is delayed in individuals with major depressive disorder (MDD). This study compared remission rates and time to remission onset for antidepressant medication delivered adjunctively to nightly time in bed (TIB) restriction of 6 hours or 8 hours for the initial 2 weeks. METHODS: Sixty-eight adults with DSM-IV-diagnosed MDD (mean ± SD age = 25.4 ± 6.6 years, 34 women) were recruited from September 2009 to December 2012 in an academic medical center. Participants received 8 weeks of open-label fluoxetine 20-40 mg and were randomized to 1 of 3 TIB conditions for the first 2 weeks: 8-hour TIB (n = 19); 6-hour TIB with a 2-hour bedtime delay (late bedtime, n = 24); or 6-hour TIB with a 2-hour rise time advance (early rise time, n = 25). Clinicians blinded to TIB condition rated symptom severity weekly. Symptom severity, remission rates, and remission onset as rated by the 17-item Hamilton Depression Rating Scale were the primary outcomes. RESULTS: Mixed effects models indicated lower depression severity for the 8-hour TIB compared to the 6-hour TIB group overall (F8, 226.9 = 2.1, P < .05), with 63.2% of 8-hour TIB compared to 32.6% of 6-hour TIB subjects remitting by week 8 (χ²1 = 4.9, P < .05). Remission onset occurred earlier for the 8-hour TIB group (hazard ratio = 0.43; 95% CI, 0.20-0.91; P < .03), with no differences between 6-hour TIB conditions. CONCLUSIONS: Two consecutive weeks of nightly 6-hour TIB does not accelerate or improve antidepressant response. Further research is needed to determine whether adequate sleep opportunity is important to antidepressant treatment response. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01545843.

A naturalistic study of suicidal adolescents treated with an SSRI: suicidal ideation and behavior during 3-month post-hospitalization period.

OBJECTIVE: Describe suicidal ideation and suicide related/other emergencies (SRE), among depressed and acutely suicidal adolescents during a 3-month period following psychiatric hospitalization. METHODS: One hundred twenty adolescents, who were both depressed and suicidal, were receiving an SSRI either alone or in combination with other medications, remained on a consistent medication regimen between baseline and at 3-months and their 3-month outcome data were available. The participants were divided into four medication groups: SSRI antidepressant only (n=71); SSRI plus mood stabilizer (n=17); SSRI plus antipsychotic (n=20); and SSRI plus antipsychotic and mood stabilizer (n=12). Standardized instruments were used. RESULTS: Mean age=15.5±1.3, Caucasian=80.8%, female=74.2%, mean CDRS-R=61.7±12.1, suicide attempt during month prior to hospitalization=58.6%. During the 3-month post-hospitalization period: (1) there were no suicides, six participants (5%) attempted suicide and 21 (17.5%) experienced an SRE; (2) decline in suicidal ideation and depression severity was noted; (3) SSRI plus an antipsychotic group reported the highest number of SREs; (4) higher baseline hopelessness and aggression scores were associated with greater reduction in suicidal ideation at 3-months. CONCLUSION: Declines in suicidal ideation, depression severity, and suicide attempts were noted, irrespective of psychotropic-combination received. A higher rate of SREs was associated with receiving an antipsychotic agent in combination with an SSRI. Given naturalistic design of study, cause-effect conclusions cannot be drawn. The lack of an objective measure to identify medication adherence is a study limitation.

Exercise for adolescents with depressive disorders: a feasibility study.

Objectives. Adolescence is associated with increased depressive symptoms and decreased aerobic exercise, yet the relationship between exercise and clinical depression among adolescents requires further examination. This study assessed the feasibility of a 12-week intervention designed to increase exercise for adolescents with depressive disorders: Will a teenager with depression exercise? Methods. Participants were 13 adolescents with depression reporting low levels of aerobic exercise. They completed a 12-week intervention (15 supervised exercise sessions and 21 independent sessions). Exercise was measured through the aerobic exercise Questionnaire, actigraphy, and heart-rate monitoring. Depression was measured with the Children's Depression Rating Scale, Revised, and Quick Inventory of Depressive Symptomatology, Self-Report. Results. All participants who started the intervention completed the protocol, attending all supervised exercise sessions. Actigraphy verified 81% adherence to the protocol's independent sessions. Analysis of secondary outcomes showed a significant increase in exercise levels and a significant decrease in depression severity. Initially, ten participants were overweight or obese, and three were healthy weight. After 12 weeks of exercise, the number of participants in the healthy-weight category doubled. Conclusions. Adolescents suffering from depression can complete a rigorous protocol requiring structured increases in aerobic exercise. Participants showed significant increases in exercise, and significant decreases in depressive symptoms.

Sleep and body mass index in depressed children and healthy controls.

OBJECTIVE: Higher body mass index (BMI) has been associated with more sleep disturbance and depressive symptoms, but the combined effects of depression and BMI on sleep have not been studied in children. This study evaluated the relationship between BMI and polysomnography in children with major depressive disorder (MDD), compared to healthy controls (HCs). METHOD: The sample of 104 subjects included 72 children, 8-17 years old, with MDD and 32 similarly aged HCs with no personal or family history of psychopathology. BMI was adjusted using the CDC formula for percentiles by age. Subjects were categorized as (1) normal weight (5-84th percentile) or (2) high weight, which included at risk of overweight and overweight (> or = 85th percentile). All analyses were adjusted for sex and Tanner maturational stage scores. RESULTS: In the MDD group only, higher BMI was significantly correlated with decreased sleep efficiency, decreased percentage of rapid eye movement sleep (REM%), and higher percentage of time spent awake and moving (TSPAM). In the HC group only, higher BMI correlated with higher total sleep time. Multivariate analyses revealed significant interactions between the BMI and diagnostic groups for several REM sleep parameters, such that high-weight children from the HC and MDD groups had increases and decreases in REM sleep, respectively. TSPAM increased in the high-weight MDD group, but decreased in the high-weight HC group. CONCLUSIONS: Although limited by small sample size, these findings suggest that children and adolescents with MDD and a high BMI have more fragmented sleep than other children. The increased REM sleep patterns observed with MDD in this and other studies normalized in high-weight children with MDD. Prevention and treatment strategies should target both sleep and weight as factors that can potentially influence the development and course of MDD.

Depression and pain in retired professional football players.

PURPOSE: To assess the prevalence of depressive symptoms and difficulty with pain in retired professional football players, difficulties with the transition from active athletic competition to retirement, perceptions of barriers to receiving assistance for those difficulties, and recommended programs to provide such assistance. METHODS: Survey sent to 3377 retired members of the National Football League Players Association (NFLPA), with usable responses received from 1617 members (functional response rate, 48.6%). RESULTS: Respondents were categorized as experiencing no to mild depression (N=1366; 84.5%) or moderate to severe depression (N=237; 14.7%). Respondents were also categorized according to whether they reported difficulty with pain as not or somewhat common (N=837; 51.8%) versus quite or very common (N=769; 47.6%). Respondents most frequently reported trouble sleeping, financial difficulties, marital or relationship problems, and problems with fitness, exercise, and aging, all of which were strongly correlated with the presence of moderate to severe depression and with quite or very common difficulty with pain. The same difficulties were even more commonly experienced by respondents who reported both moderate to severe depression and quite or very common difficulty with pain, compared with those who reported low scores in both domains. CONCLUSION: Retired professional football players experience levels of depressive symptoms similar to those of the general population, but the impact of these symptoms is compounded by high levels of difficulty with pain. The combination of depression and pain is strongly predictive of significant difficulties with sleep, social relationships, financial difficulties, and problems with exercise and fitness. A hypothesis explaining this association is that significant musculoskeletal disability and chronic pain interferes with physical activity and fitness during retirement and increases the risk of depression.