Adolescents' Hormonal Responses to Social Stress and Associations with Adolescent Social Anxiety and Maternal Comfort: A Preliminary Study.

Both social support and social stress can impact adolescent physiology including hormonal responses during the sensitive transition to adolescence. Social support from parents continues to play an important role in socioemotional development during adolescence. Sources of social support and stress may be particularly impactful for adolescents with social anxiety symptoms. The goal of the current study was to examine whether adolescent social anxiety symptoms and maternal comfort moderated adolescents' hormonal response to social stress and support. We evaluated 47 emotionally healthy 11- to 14-year-old adolescents' cortisol and oxytocin reactivity to social stress and support using a modified version of the Trier Social Stress Test for Adolescents that included a maternal comfort paradigm. Findings demonstrated that adolescents showed significant increases in cortisol and significant decreases in oxytocin following the social stress task. Subsequently, we found that adolescents showed significant decreases in cortisol and increases in oxytocin following the maternal comfort paradigm. Adolescents with greater social anxiety symptoms showed higher levels of cortisol at baseline but greater declines in cortisol response following maternal social support. Social anxiety symptoms were unrelated to oxytocin response to social stress or support. Our findings provide further evidence that mothers play a key role in adolescent regulation of physiological response, particularly if the stressor is consistent with adolescents' anxiety. More specifically, our findings suggest that adolescents with higher social anxiety symptoms show greater sensitivity to maternal social support following social stressors. Encouraging parents to continue to serve as a supportive presence during adolescent distress may be helpful for promoting stress recovery during the vulnerable transition to adolescence.

Clinical Trainee Perspectives on the Implementation of Trauma-Focused Training.

OBJECTIVE: Despite the high prevalence of trauma exposure in the United States and calls for the implementation of trauma-focused psychotherapy training, scant opportunities exist for such training in graduate clinical psychology programs. This study aimed to guide the implementation of trauma-focused psychotherapy training in graduate curricula by examining clinical trainees' perspectives on their current training and desired features for trauma-specific learning environments. The absence of research that centers trainee voices is notable; therefore, this study specifically focuses on trainee perspectives on implementation. METHODS: The New Haven competencies, developed by the American Psychological Association to support efforts to improve trauma-specific training, were used as a framework to guide the development of a mixed-methods survey. Current doctoral students (N=18) in one clinical psychology program completed the survey. RESULTS: Trainees overwhelmingly perceived the competencies to be relevant to their psychological assessment and therapy training and to their professional goals but noted a general lack of available trauma-specific training. Nearly all trainees believed that trauma-specific training should be required and expressed varied opinions regarding how requirements should be structured. Important features of a safe and supportive learning environment were reported to include coconstructed norms, choice and flexibility for participation, and integrated wellness practices. Further, instructors' trauma awareness, cultural humility, and responsiveness to students' experiences were emphasized by trainees as important. CONCLUSIONS: Effective implementation of trauma-specific psychotherapy training should be guided by ongoing dialogue between trainees and training stakeholders.

Assessing Aspects of Social Relationships in Youth Across Middle Childhood and Adolescence: The NIH Toolbox Pediatric Social Relationship Scales.

OBJECTIVE: Social relationships are a critical context for children's socioemotional development and their quality is closely linked with concurrent and future physical and emotional wellbeing. However, brief self-report measures of social relationship quality that translate across middle childhood, adolescence, and adulthood are lacking, limiting the ability to assess the impact of social relationships on health outcomes over time. To address this gap, this article describes the development and testing of the National Institutes of Health (NIH) Toolbox Pediatric Social Relationship Scales, which were developed in parallel with the previously-reported Adult Social Relationship Scales. METHODS: Item sets were selected from the NIH Toolbox adult self-report item banks in the domains of social support, companionship, and social distress, and adapted for use in preadolescent (ages 8-11 years) and adolescent (ages 12-18 years) cohorts. Items were tested across a U.S. community sample of 1,038 youth ages 8-18 years. Classical test and item response theory approaches were used to identify items for inclusion in brief unidimensional scales. Concurrent validity was assessed by comparing resultant scales to established pediatric social relationship instruments. RESULTS: Internal reliability and concurrent validity were established for five unique scales, with 5-7 items each: Emotional Support, Friendship, Loneliness, Perceived Rejection, and Perceived Hostility. CONCLUSIONS: These brief scales represent developmentally appropriate and valid instruments for assessing the quality of youth social relationships across childhood and adolescence. In conjunction with previously published adult scales, they provide an opportunity for prospective assessment of social relationships across the developmental spectrum.

Changes in inflammation with treatment for bipolar II depression: Pilot trial data on differential effects of psychotherapy and medication.

OBJECTIVES: Limited prospective data, mostly focused on bipolar I disorder, suggests that pro-inflammatory cytokines are elevated in abnormal mood states. We evaluated whether treatment normalizes peripheral markers of inflammation in bipolar II disorder. METHODS: Using data from a randomized clinical trial of Interpersonal and Social Rhythm Therapy (IPSRT) + quetiapine vs. IPSRT + placebo for bipolar II depression, we examined whether these treatments for bipolar II depression impact inflammatory cytokines and whether observed changes in cytokines are associated with changes in depressive symptomatology as measured by the Hamilton Rating Scale for Depression (HRSD-17). RESULTS: Cytokine values were available for 33 participants who completed baseline and 20-week followup visits. After excluding those with CRP values >=10 mg/L, there were 27 patients available for analysis (IPSRT+quetiapine N=10, IPSRT+placebo N=17). Baseline measure of inflammation did not appear to moderate treatment response, nor was change in HRSD-17 score correlated with changes in cytokines. Those who received IPSRT+quetiapine had significantly greater increases in IL-6 (p=0.02) and TNF-α (p=0.04), even after adjusting for changes in body mass index, than the IPSRT alone group. Descriptively, the quetiapine group showed increases in pro-inflammatory and decreases in anti-inflammatory cytokines and the psychotherapy group showed reduced pro-inflammatory cytokines. CONCLUSIONS: Despite both groups showing depression improvement, this small study suggests a more pro-inflammatory cytokine profile over time with quetiapine plus psychotherapy compared to psychotherapy alone. Elevated risk of cardiovascular morbidity and mortality among those with bipolar II disorder underscores the importance of delivering treatments that do not exacerbate these risk factors.

Moderators and mediators of a maternal depression treatment study: Impact of maternal trauma and parenting on child outcomes.

OBJECTIVE: Treatment of maternal depression with psychotherapy has been shown to confer indirect benefits to school-age offspring with psychiatric disorders. The current study sought to understand mechanisms by which improvement in depressed mothers, with and without histories of trauma and treated with psychotherapy, produce changes in children who struggle with psychiatric illnesses themselves. We hypothesized that maternal history of childhood trauma would moderate the relationship between maternal and child outcomes and that increased positive and decreased negative parenting behaviors would mediate the relationship between maternal and child outcomes. We also examined whether maternal history of trauma would moderate the mediational effects of parenting behaviors. METHODS: Participants were dyads (n = 62) of mothers with major depressive disorder and their children, ages 7-18, with at least one internalizing disorder. Mothers were treated with nine sessions of psychotherapy and children were treated openly in the community. Dyads were evaluated every three months over one year. RESULTS: Maternal improvement in depressive symptoms was associated, in a lagged fashion, with child improvement in functioning six months later. There was a significant interaction of time and change in maternal symptoms [F(1, 45) = 5.84, p = 0.02], where change in maternal depressive symptoms from baseline to six months was robustly associated with change in child functioning from baseline to 12 months (ß = 0.49, p = 0.0002). Maternal history of childhood sexual abuse moderated the association between change in maternal and child depressive symptoms [F(1,87) = 5.8, p = 0.02], and maternal history of physical neglect moderated the relationship between improvement in maternal depression and improvement in child functioning [F(1,36) = 4.34, p = 0.04], where significant associations between maternal and child outcomes were only found in mothers without histories of sexual abuse or physical neglect. Increase in positive parenting strategies (acceptance) by mothers mediated 6-month lagged associations between maternal and child outcomes, but reduction in negative parenting strategies (psychological control) did not. Maternal history of childhood emotional neglect moderated the mediational model, such that improved positive parenting did not explain lagged improvement in child depression among the subset of mothers with childhood histories of emotional neglect. CONCLUSIONS: In dyads comprised of depressed mothers and school-age children with internalizing disorders, children improved when mothers improved, but not among those whose mothers who had histories of sexual abuse or physical neglect. Increased use of positive parenting strategies among mothers accounted for lagged relationships between improvement in maternal depressive symptoms and improvement in child functioning. This pattern was not, however, observed among mothers with childhood histories of emotional neglect. Interventions that directly enhance positive parenting and more rapidly change these behaviors may hasten improvement in offspring. Offspring of depressed mothers with histories of early trauma are at high risk for poor outcomes, even when their mothers receive depression treatment.

Depression impacts the physiological responsiveness of mother-daughter dyads during social interaction.

BACKGROUND: Maternal depression is associated with increased risk of psychiatric illness in offspring. While risk may relate to depressed mothers' difficulties regulating emotions in the context of interacting with offspring, physiological indicators of emotion regulation have rarely been examined during mother-child interactions-and never among mother-adolescent dyads in which both mother and adolescent have histories of major depressive disorder (MDD). METHODS: We examined changes in high-frequency heart rate variability (HF-HRV), an indicator of parasympathetic (vagal) function that has been related to depression, stress, social engagement, and emotion regulation, in 46 mother-daughter dyads (23 in which both mother and daughter had an MDD history and 23 never-depressed controls). Hierarchical linear models evaluated changes in HF-HRV while mother-daughter dyads engaged in discussions about shared pleasant events and relationship conflicts. RESULTS: While control dyads displayed positive slopes (increases) in HF-HRV during both discussions, MDD dyads displayed minimal change in HF-HRV across discussions. Among controls, HF-HRV slopes were positively correlated between mothers and daughters during the pleasant events' discussion. In contrast, HF-HRV slopes were negatively correlated between MDD mothers and daughters during both discussions. CONCLUSIONS: Vagal responses observed in control mother-daughter dyads suggest a pattern of physiological synchrony and reciprocal positive social engagement, which may play a role in adolescent development of secure social attachments and healthy emotion regulation. In contrast, MDD mothers and daughters displayed diminished and discordant patterns of vagal responsiveness. More research is needed to understand the development and consequences of these patterns of parasympathetic responses among depressed mother-daughter dyads.

The role of family history of depression and the menopausal transition in the development of major depression in midlife women: Study of women's health across the nation mental health study (SWAN MHS).

BACKGROUND: This study evaluated whether family history of depression predicts major depression in midlife women above and beyond static risk factors (such as personal history of depression prior to midlife) and risks that may change dynamically across midlife (such as menopausal, psychosocial, and health profiles). METHODS: Participants were 303 African American and Caucasian women (42-52 years at baseline) recruited into the Study of Women's Health across the Nation (SWAN) Mental Health Study (MHS) in Pittsburgh. Major depression was assessed annually with Structured Clinical Interviews for DSM-IV. Family mental health history was collected at the ninth or tenth annual follow-up. Random effects logistic regression was used to assess the relationship between family history of depression and midlife depression, controlling for baseline sociodemographic characteristics and time-varying risk factors. RESULTS: Family history of depression was associated with midlife depression after adjusting for participant's history of major depression prior to midlife, trait anxiety and baseline age, and time-varying menopausal status, body mass index, very upsetting life events, and chronic difficulties (OR = 2.24, 95% CI = 1.17-4.29, P = .02). Higher odds of major depression were found when women were late perimenopausal or postmenopausal relative to when they were premenopausal or early perimenopausal (OR = 3.01, 95% CI = 1.76-5.15, P < .0001). However, menopausal status was only associated with major depression among women without a family history. CONCLUSIONS: Family history of depression predicts major depression in midlife women independent of the menopausal transition and other time-varying covariates. Notably, the menopausal transition was associated with increased risk only among women without a family history of depression.

Prospective assessment of social network quality among depressed mothers treated with brief psychotherapy: The Social Network Quality (SNQ) scales.

OBJECTIVE: Social relationships play important roles in emotional health, and are common targets of psychotherapeutic interventions. To better evaluate social relationship structure and function in the context of psychotherapy trials, this study introduces and psychometrically evaluates the Social Network Quality (SNQ) scales, which supplement the Social Network Index (SNI). The original SNI evaluates social network structure (i.e., extent of participation in diverse social roles and number of social relationships). The SNQ adds two social network quality scales evaluating levels of: (a) positivity/support, and (b) negativity/stress, within and across specific social roles. METHOD: Participants included 168 depressed mothers of psychiatrically-ill children participating in a psychotherapy treatment trial utilizing interpersonal therapy (IPT) and brief supportive therapy (BSP). The SNI, SNQ, and measures of social functioning and psychopathology were collected at baseline and at 3-month intervals over a one-year period. RESULTS: SNQ scores showed meaningful concurrent relationships with measures of social support and interpersonal distress, as well as incremental utility in explaining variance in relationship and mood outcomes above and beyond the SNI. SNQ scores also detected global and relationship-specific changes in social relationship quality following psychotherapy treatment. CONCLUSION: This report demonstrates that SNQ scales reliably assess psychotherapy-induced changes in relationship quality.

Therapist Use of Specific and Nonspecific Strategies Across Two Affect-Focused Psychotherapies for Depression: Role of Adherence Monitoring.

Psychotherapists routinely use both specific and non-specific strategies to deliver empirically supported treatments (ESTs). Psychotherapy adherence monitoring has traditionally focused on assessing therapist use of EST-specific strategies (to distinguish between ESTs), paying less attention to non-specific techniques common to multiple psychotherapies. This study used the Collaborative Study Psychotherapy Rating Scale (CSPRS) to evaluate therapist use of both specific and non-specific techniques in two affect-focused ESTs for depression. Blinded raters evaluated 180 recorded sessions of interpersonal psychotherapy (IPT) and brief supportive psychotherapy (BSP). Because IPT and BSP both emphasize attention to affective states and developing a warm therapy relationship, we expected overlap across scales measuring therapist warmth, empathy, and focus on feelings. In contrast, we expected differences in scales measuring therapist directiveness, as well as IPT- and BST-specific interventions. Results showed raters displayed good inter-rater reliability on primary subscales and could discriminate between two treatments with considerable overlap. Both IPT and BSP therapists used similarly high levels of non-specific, facilitative interventions. Expectedly, IPT therapists were more directive and used more IPT-specific strategies, while BSP therapists utilized more non-directive, supportive strategies. Unexpectedly, BSP therapists showed greater focus on feelings than IPT therapists. Exploratory analyses suggested that greater focus on feelings in early sessions was associated with greater depressive symptom reduction in the first eight weeks of treatment for both ESTs. Additional treatment adherence research is needed to investigate both shared and distinctive features of ESTs, as well as the effect of the relative use of specific versus non-specific interventions on psychotherapy outcomes.

Sexual Satisfaction and the Importance of Sexual Health to Quality of Life Throughout the Life Course of U.S. Adults.

INTRODUCTION: Discussions about sexual health are uncommon in clinical encounters, despite the sexual dysfunction associated with many common health conditions. Understanding of the importance of sexual health and sexual satisfaction in U.S. adults is limited. AIM: To provide epidemiologic data on the importance of sexual health for quality of life and people's satisfaction with their sex lives and to examine how each is associated with demographic and health factors. METHODS: Data are from a cross-sectional self-report questionnaire from a sample of 3,515 English-speaking U.S. adults recruited from an online panel that uses address-based probability sampling. MAIN OUTCOME MEASURES: We report ratings of importance of sexual health to quality of life (single item with five-point response) and the Patient-Reported Outcomes Measurement Information System Satisfaction With Sex Life score (five items, each with five-point responses, scores centered on the U.S. mean). RESULTS: High importance of sexual health to quality of life was reported by 62.2% of men (95% CI = 59.4-65.0) and 42.8% of women (95% CI = 39.6-46.1, P < .001). Importance of sexual health varied by sex, age, sexual activity status, and general self-rated health. For the 55% of men and 45% of women who reported sexual activity in the previous 30 days, satisfaction with sex life differed by sex, age, race-ethnicity (among men only), and health. Men and women in excellent health had significantly higher satisfaction than participants in fair or poor health. Women with hypertension reported significantly lower satisfaction (especially younger women), as did men with depression or anxiety (especially younger men). CONCLUSION: In this large study of U.S. adults' ratings of the importance of sexual health and satisfaction with sex life, sexual health was a highly important aspect of quality of life for many participants, including participants in poor health. Moreover, participants in poorer health reported lower sexual satisfaction. Accordingly, sexual health should be a routine part of clinicians' assessments of their patients. Health care systems that state a commitment to improving patients' overall health must have resources in place to address sexual concerns. These resources should be available for all patients across the lifespan.

Development and Initial Validation of the PROMIS(®) Sexual Function and Satisfaction Measures Version 2.0.

INTRODUCTION: The Patient-Reported Outcomes Measurement Information System (PROMIS)(®) Sexual Function and Satisfaction measure (SexFS) version 1.0 was developed with cancer populations. There is a need to expand the SexFS and provide evidence of its validity in diverse populations. AIM: The aim of this study was to describe the development of the SexFS v2.0 and present preliminary evidence for its validity. METHODS: Development built on version 1.0, plus additional review of extant items, discussions with 15 clinical experts, 11 patient focus groups (including individuals with diabetes, heart disease, anxiety, depression, and/or are lesbian, gay, bisexual, or aged 65 or older), 48 cognitive interviews, and psychometric evaluation in a random sample of U.S. adults plus an oversample for specific sexual problems (2281 men, 1686 women). We examined differential item functioning (DIF) by gender and sexual activity. We examined convergent and known-groups validity. RESULTS: The final set of domains includes 11 scored scales (interest in sexual activity, lubrication, vaginal discomfort, clitoral discomfort, labial discomfort, erectile function, orgasm ability, orgasm pleasure, oral dryness, oral discomfort, satisfaction), and six nonscored item pools (screeners, sexual activities, anal discomfort, therapeutic aids, factors interfering with sexual satisfaction, bother). Domains from version 1.0 were reevaluated and improved. Domains considered applicable across gender and sexual activity status, namely interest, orgasm, and satisfaction, were found to have significant DIF. We identified subsets of items in each domain that provided consistent measurement across these important respondent groups. Convergent and known-groups validity was supported. CONCLUSIONS: The SexFS version 2.0 has several improvements and enhancements over version 1.0 and other extant measures, including expanded evidence for validity, scores centered around norms for sexually active U.S. adults, new domains, and a final set of items applicable for both men and women and those sexually active with a partner and without. The SexFS is customizable, allowing users to select relevant domains and items for their study.

Does family history of depression predict major depression in midlife women? Study of Women's Health Across the Nation Mental Health Study (SWAN MHS).

This study aims to determine whether family history of depression predicts major depression in midlife women independent of psychosocial and health profiles at midlife. Participants were 303 African American and Caucasian women (42-52 years at baseline) recruited into the Study of Women's Health Across the Nation (SWAN) and the Women's Mental Health Study (MHS) in Pittsburgh. Major depression was assessed annually with the Structured Clinical Interview for DSM-IV. Family mental health history was collected at the ninth or tenth follow-up. Multivariable logistic regression was used to determine whether family history of depression predicted major depression in midlife, adjusting for covariates. The odds of experiencing major depression during the study were three times greater for those with a family history than for those without a family history (OR = 3.22, 95% CI = 1.95-5.31). Family history predicted depression (OR = 2.67, 95% CI = 1.50-4.78) after adjusting for lifetime history of depression, age, trait anxiety, chronic medical conditions, and stressful life events. In analyses stratified by lifetime history of depression, family history significantly predicted depression only among women with a lifetime history of depression. Family history of depression predicts major depression in midlife women generally, but particularly in those with a lifetime history of depression prior to midlife.

Development of the NIH PROMIS ® Sexual Function and Satisfaction measures in patients with cancer.

INTRODUCTION: We describe the development and validation of the Patient-Reported Outcomes Measurement Information System(®) Sexual Function and Satisfaction (PROMIS(®) SexFS; National Institutes of Health) measures, version 1.0, for cancer populations. AIM: To develop a customizable self-report measure of sexual function and satisfaction as part of the U.S. National Institutes of Health PROMIS Network. METHODS: Our multidisciplinary working group followed a comprehensive protocol for developing psychometrically robust patient-reported outcome measures including qualitative (scale development) and quantitative (psychometric evaluation) development. We performed an extensive literature review, conducted 16 focus groups with cancer patients and multiple discussions with clinicians, and evaluated candidate items in cognitive testing with patients. We administered items to 819 cancer patients. Items were calibrated using item-response theory and evaluated for reliability and validity. MAIN OUTCOME MEASURES: The PROMIS SexFS measures, version 1.0, include 81 items in 11 domains: Interest in Sexual Activity, Lubrication, Vaginal Discomfort, Erectile Function, Global Satisfaction with Sex Life, Orgasm, Anal Discomfort, Therapeutic Aids, Sexual Activities, Interfering Factors, and Screener Questions. RESULTS: In addition to content validity (patients indicate that items cover important aspects of their experiences) and face validity (patients indicate that items measure sexual function and satisfaction), the measure shows evidence for discriminant validity (domains discriminate between groups expected to be different) and convergent validity (strong correlations between scores on PROMIS and scores on conceptually similar older measures of sexual function), as well as favorable test-retest reliability among people not expected to change (interclass correlations from two administrations of the instrument, 1 month apart). CONCLUSIONS: The PROMIS SexFS offers researchers a reliable and valid set of tools to measure self-reported sexual function and satisfaction among diverse men and women. The measures are customizable; researchers can select the relevant domains and items comprising those domains for their study.

Role of maternal childhood trauma on parenting among depressed mothers of psychiatrically ill children.

BACKGROUND: Independently, maternal depression and maternal history of childhood abuse confer risk for impaired parenting. These associations may be compounded when depressed mothers with histories of childhood abuse are faced with the challenge of parenting offspring who themselves struggle with mental health problems. This study examined the relationships among maternal history of childhood abuse, maternal depression, and parenting style in the context of parenting a psychiatrically ill child, with an emphasis on examining maternal emotional abuse and neglect. We hypothesized that maternal childhood emotional abuse would be associated with maladaptive parenting strategies (lower levels of maternal acceptance and higher levels of psychological control), independent of maternal depression severity and other psychosocial risk factors. METHOD: Ninety-five mother-child dyads (children ages 7-18) were recruited from child mental health centers where children were receiving treatment for at least one internalizing disorder. Participating mothers met DSM-IV criteria for major depressive disorder. Mothers reported on their own childhood abuse histories and children reported on their mothers' parenting. RESULTS: Regression analyses demonstrated that maternal childhood emotional abuse was associated with child reports of lower maternal acceptance and greater psychological control, controlling for maternal depression severity, and other psychosocial risk factors. CONCLUSIONS: When treating psychiatrically ill children, it is important for a child's clinician to consider mothers' childhood abuse histories in addition to their history of depression. These mothers appear to have additional barriers to effective parenting.

Construct validity of the PROMIS® sexual function and satisfaction measures in patients with cancer.

BACKGROUND: With data from a diverse sample of patients either in treatment for cancer or post-treatment for cancer, we examine inter-domain and cross-domain correlations among the core domains of the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction measures (PROMIS® SexFS) and the corresponding domains from conceptually-similar measures of sexual function, the International Index of Erectile Function and the Female Sexual Function Index. FINDINGS: Men (N=389) and women (N=430) were recruited from a tumor registry, oncology clinics, and an internet panel. The PROMIS SexFS, International Index of Erectile Function, and Female Sexual Function Index were used to collect participants' self-reported sexual function. The domains shared among the measures include desire/interest in sexual activity, lubrication and vaginal discomfort/pain (women), erectile function (men), orgasm, and satisfaction. We examined correlations among different domains within the same instrument (discriminant validity) and correlations among similar domains measured by different instruments (convergent validity). Correlations demonstrating discriminant validity ranged from 0.38 to 0.73 for men and 0.48 to 0.74 for women, while correlations demonstrating convergent validity ranged from 0.62 to 0.83 for men and 0.71 to 0.92 for women. As expected, correlations demonstrating convergent validity were higher than correlations demonstrating discriminant validity, with one exception (orgasm for men). CONCLUSIONS: Construct validity was supported by convergent and discriminant validity in a diverse sample of patients with cancer. For patients with cancer who may or may not have sexual dysfunction, the PROMIS SexFS measures provide a comprehensive assessment of key domains of sexual function and satisfaction.

Psychosocial features associated with lifetime comorbidity of major depression and anxiety disorders among a community sample of mid-life women: the SWAN mental health study.

BACKGROUND: In clinical samples, comorbidity between depressive and anxiety disorders is associated with greater symptom severity and elevated suicide risk. Less is known, however, regarding the long-term psychosocial impact that a lifetime history of both major depressive disorder (MDD) and one or more anxiety disorders has in community samples. This report evaluates clinical, psychological, social, and stress-related characteristics associated with a lifetime history of MDD and anxiety. METHODS: Data from 915 women aged 42-52 who were recruited as part of the the Study of Women's Health across the Nation (SWAN) Mental Health Study were used to examine clinical and psychosocial features across groups of women with a lifetime history of MDD alone, anxiety alone, both MDD and anxiety, or neither MDD nor anxiety. RESULTS: As compared with women with a history of either MDD or anxiety alone, women with a comorbid history were more likely to report recurrent MDD, multiple and more severe lifetime anxiety disorders, greater depressive and anxiety symptoms, diminished social support, and more past-year distressing life events. Exploratory analyses indicated that women with a comorbid history also report more childhood abuse/neglect and diminished self-esteem, as compared with women with a history of either disorder alone. CONCLUSIONS: Midlife women with a comorbid history that includes both MDD and anxiety disorders report diminished social support, more symptomatic distress, and a more severe and recurrent psychiatric history. Future research is needed to clarify the biological and psychosocial risk factors associated with this comorobid profile, and to develop targeted interventions for this at-risk group. Depression and Anxiety 00:1-8, 2012. © 2012 Wiley Periodicals, Inc.

Cardiac vagal control in nonmedicated depressed women and nondepressed controls: impact of depression status, lifetime trauma history, and respiratory factors.

OBJECTIVE: To evaluate the impact of acute stress and relationship-focused imagery on cardiac vagal control, as indicated by levels of respiratory sinus arrhythmia (RSA), in depressed and nondepressed women. Impairment in cardiac parasympathetic (vagal) control may confer risk for cardiac mortality in depressed populations. METHODS: Electrocardiogram and respiratory rate were evaluated in 15 nonmedicated depressed women and 15 matched controls during two laboratory conditions: 1) a relationship-focused imagery designed to elicit vagal activation; and 2) a speech stressor designed to evoke vagal withdrawal. RESULTS: As expected, the relationship-focused imagery increased RSA (F(3,66) = 3.79, p = .02) and the speech stressor decreased RSA (F(3,66) = 4.36, p = .02) across women. Depressed women exhibited lower RSA during the relationship-focused imagery, and this effect remained after control for respiratory rate and trauma history (F(1,21) = 5.65, p = .027). Depressed women with a trauma history exhibited the lowest RSA during the stress condition (F(1,22) = 9.61, p = .05). However, after controlling for respiratory rate, Trauma History × Task Order (p = .02) but not Trauma History × Depression Group (p = .12) accounted for RSA variation during the stress condition. CONCLUSION: Depression in women is associated with lower RSA, particularly when women reflect on a close love relationship, a context expected to elicit vagal activation and hence increase RSA. In contrast, depression-related variation in stressor-evoked vagal activity seems to covary with women's trauma history. Associations between vagal activity and depression are complex and should be considered in view of the experimental conditions under which vagal control is assessed, as well as physiological and behavioral factors that may affect vagal function.

Are there bi-directional associations between depressive symptoms and C-reactive protein in mid-life women?

OBJECTIVE: To test whether depressive symptoms are related to subsequent C-reactive protein (CRP) levels and/or whether CRP levels are related to subsequent depressive symptoms in mid-life women. METHODS: Women enrolled in the Study of Women's Health Across the Nation (SWAN) were followed for 7years and had measures of CES-Depression scores and CRP seven times during the follow-up period. Women were pre- or early peri-menopausal at study entry and were of Caucasian, African American, Hispanic, Japanese, or Chinese race/ethnicity. Analyses were restricted to initially healthy women. RESULTS: Longitudinal mixed linear regression models adjusting for age, race, site, time between exams, and outcome variable at year X showed that higher CES-D scores predicted higher subsequent CRP levels and vice versa over a 7-year period. Full multivariate models adjusting for body mass index, physical activity, medications, health conditions, and other covariates showed that higher CRP levels at year X predicted higher CES-D scores at year X+1, p=0.03. Higher depressive symptoms predicted higher subsequent CRP levels at marginally significant levels, p=0.10. CONCLUSIONS: Higher CRP levels led to higher subsequent depressive symptoms, albeit the effect was small. The study demonstrates the importance of considering bi-directional relationships for depression and other psychosocial factors and risk for heart disease.

Treating depression to remission in older adults: a controlled evaluation of combined escitalopram with interpersonal psychotherapy versus escitalopram with depression care management.

OBJECTIVE: More than half of the older adults respond only partially to first-line antidepressant pharmacotherapy. Our objective was to test the hypothesis that a depression-specific psychotherapy, Interpersonal Psychotherapy (IPT), when used adjunctively with escitalopram, would lead to a higher rate of remission and faster resolution of symptoms in partial responders than escitalopram with depression care management (DCM). METHOD: We conducted a 16-week randomized clinical trial of IPT and DCM in partial responders to escitalopram, enrolling 124 outpatients aged 60 and older. The primary outcome, remission, was defined as three consecutive weekly scores of 7 or less on the Hamilton rating scale for depression (17-item). We conducted Cox regression analyses of time to remission and logistic modeling for rates of remission. We tested group differences in Hamilton depression ratings over time via mixed-effects modeling. RESULTS: Remission rates for escitalopram with IPT and with DCM were similar in intention-to-treat (IPT vs. DCM: 58 [95% CI: 46, 71] vs. 45% [33,58]; p = 0.14) and completer analyses (IPT vs. DCM: 58% [95% CI: 44,72] vs. 43% [30,57]; p = 0.20). Rapidity of symptom improvement did not differ in the two treatments. CONCLUSION: No added advantage of IPT over DCM was shown. DCM is a clinically useful strategy to achieve full remission in about 50% of partial responders.

Emotional and cardiovascular reactivity to a child-focused interpersonal stressor among depressed mothers of psychiatrically ill children.

BACKGROUND: Impairment in maternal interpersonal function represents a risk factor for poor psychiatric outcomes among children of depressed mothers. However, the mechanisms by which this effect occurs have yet to be fully elucidated. Elevated levels of emotional or physiological reactivity to interpersonal stress may impact depressed mothers' ability to effectively negotiate child-focused conflicts. This effect may become particularly pronounced when depressed mothers are parenting a psychiatrically ill child. METHODS: The current feasibility study evaluated mothers' emotional and cardiovascular reactivity in response to an acute, child-focused stress task. Twenty-two depressed mothers of psychiatrically ill children were recruited from a larger clinical trial; half were randomly assigned to receive an adapted form of interpersonal psychotherapy (IPT-MOMS), while the other half received treatment as usual (TAU). For comparison purposes, a matched sample of 22 nondepressed mothers of psychiatrically healthy children was also evaluated. RESULTS: Depressed mothers receiving minimal-treatment TAU displayed the greatest increases in depressed mood, heart rate, and diastolic blood pressure in response to the child-focused stress task, and significantly differed from the relatively low levels of reactivity observed among nondepressed mothers of healthy children. In contrast, depressed mothers receiving IPT-MOMS displayed patterns of reactivity that fell between these extreme groups. Maternal stress reactivity was associated not only with maternal psychiatric symptoms, but also with levels of chronic parental stress and maternal history of childhood emotional abuse. CONCLUSIONS: Future, more definitive research is needed to evaluate depressed mothers' interpersonal stress reactivity, its amenability to treatment, and its long-term impact on child psychiatric outcomes.