Interactions Between Serotonin Transporter Gene and Adverse Childhood Experience in a Generalized Additive Model: A Pilot Study.

BACKGROUND: While most people experience potentially traumatic events (PTEs), including Adverse Childhood Experiences (ACEs), the stress reactions to PTEs on mental health outcomes are highly heterogeneous. Resilience is influenced by a complex biopsychosocial ecological system, including gene serotonin transporter-linked promoter region or 5-HTTLPR /rs25531 by ACEs interactions. AIMS: This pilot study investigated the gene-by-environment interactions on mental health outcomes in adults enrolled in a health care profession program using a generalized additive model (GAM). METHODS: Seventy health care college students (mean age = 27.4 years, 67.1% women) participated in this cross-sectional study. Saliva samples were collected from students to analyze 5-HTTLPR/rs25531. Participants completed the ACE Questionnaire and the Mental Health Inventory. GAMs with different interaction terms were built adjusting for age, gender, and race. The value of the effective degree of freedom (EDF) quantifies the curvature of the relationship. RESULTS: Among participants with the long allele of 5-HTTLPR/rs25531, a linear pattern was found between the total ACE score and mental health outcomes (EDF = 1). Conversely, among participants with the short allele, EDF was approximately 2, indicating a curved association suggesting that mental health worsens in individuals exposed to up to four types of ACEs. CONCLUSIONS: The impact of up to four ACEs on mental health was stronger among individuals with the short allele of 5-HTTLPR/rs25531 than those with the long allele. Although this study does not claim to provide a definite approach to analyzing gene-by-environment interactions, we offer a different perspective to explore the relationship.

Identification of Relationships Among Resilience Factors Using Network Analysis: A Pilot Study.

BACKGROUND: Although college life can be fulfilling, it can be stressful, particularly for health professional students. In addition, they may have had Adverse Childhood Experience (ACE) that increases their sensitivity to academic stress. Yet, students need to overcome challenges to become successful professionals. The literature suggests the following factors may be associated with resilience: ACE and academic stress as the antecedents; ego-resilience, emotion regulation, resources, social support, inflammatory markers, and genes as the defining attributes; and mental health and sense of coherence (SOC) as the consequences. AIMS: The purpose is to identify the relationships among factors associated with resilience using network analysis. METHODS: A total of 70 college students participated in this cross-sectional pilot study. They completed measures of psychosocial variables and provided saliva samples, which were analyzed for Serotonin Transporter-Linked Promoter Region (5-HTTLPR)/rs25531 and inflammatory markers. Mixed graphical models including all variables were estimated using the R-package mgm. RESULTS: Network analysis revealed positive associations between (1) mental health and SOC; (2) mental health and resources; (3) mental health and social support; (4) SOC and reappraisal of emotion regulation; (5) resources and reappraisal of emotion regulation; and (6) resources and social support. In addition, SOC and academic stress were negatively associated. Furthermore, the short variant of 5-HTTLPR/rs25531 was associated with stronger suppression of emotion regulation and fewer resources compared with the long variant. CONCLUSION: Resilience may be influenced by biopsychosocial factors, notably SOC and 5-HTTLPR/rs25531. However, longitudinal research is needed with a larger sample size to better understand how these and other factors may affect resilience.

Genetic associations with resilience to potentially traumatic events and vantage sensitivity to social support.

INTRODUCTION: Stress responses and mental health outcomes greatly vary when individuals are exposed to potentially traumatic events (PTEs). The Differential Susceptibility Model (DSM) (Pluess, 2015) suggests individual differences in stress responses are influenced by gene-environment interactions, with genes conferring reactivity. While individuals can be resilient (or vulnerable) to PTEs, they can also have vantage sensitivity (or resistance) to social support. This study examined whether selected genotypes moderated the effect of PTEs and social support on mental health. METHODS: This cross-sectional candidate gene study included 450 college students (M age = 20.4, 79.3 % women) who provided buccal cells for genotyping and completed measures of psychosocial variables. DNA was genotyped for 12 genetic variants. RESULTS: Hierarchical regression revealed that the Mental Health Inventory (MHI) was associated with the Trauma History Questionnaire (THQ), rs1800795 in IL-6, and THQ × rs1800795 [R2 = 0.10, F(3, 418) = 15.68, p < .01]. The MHI was associated with the Social Support Survey (SSS), rs4680 in COMT, and SSS × rs4680 [R2 = 0.24, F(3, 429) = 44.19, p < .01]. Only THQ and SSS survived multiple testing corrections. DISCUSSION: Findings partially support the DSM that the G/G genotype of rs1800795 in IL-6 is associated with resilience to PTEs, and the Met/Met genotype of rs4680 in COMT is associated with vantage sensitivity to social support. Limitations include cross-sectional design, limited PTE measurement, small convenience sample, and noncorrection for multiple significance test. Clinicians need to view resilience holistically and understand resilience is associated with psychosocial and genetic factors.

Social Support Buffers the Effects of Prenatal Depressed Mood: A Mixed-Methods Study.

BACKGROUND: Women use various coping strategies to deal with stress and depression. These strategies are shaped by social contexts over the life course and may attenuate and/or exacerbate the physiologic effects of depression. AIMS: The purpose of this study was to determine whether coping strategies (active, disengaged, or social support coping) moderate depression-related diurnal cortisol dysregulation and to explore how social context influences women's use of coping. METHODS: This was a mixed-methods study of pregnant women (N = 65) during mid-pregnancy. Cortisol was measured in saliva collected during the waking hours of the day. Participants completed the Edinburgh Depression Scale and the Brief COPE. A subset of the sample participated in semistructured qualitative interviews (n = 20). RESULTS: Social support coping, but not active or disengaged coping, moderated end-of-day cortisol levels. Among depressed women, higher use of social support was associated with lower and more dynamic (i.e., less flat) diurnal cortisol rhythms. The qualitative findings revealed how complex social dynamics related to financial insecurity, lack of mutuality, and social identity affected women's use of and access to social support. CONCLUSION: These findings support theories of the stress-buffering effects of social support. Future research is needed to examine how social determinants affect access to social support, and how early life social experiences condition women's adaptive formation of social support coping strategies over the life course. Clinically, these findings underscore the value of relationship-centered nursing care for depressed women.

Integrative Review of Early Life Adversity and Cortisol Regulation in Pregnancy.

OBJECTIVE: To synthesize published findings on the relationship between early life adversity and hypothalamic-pituitary-adrenal axis cortisol parameters in pregnant women. DATA SOURCES: We searched PubMed, CINAHL, and PsycINFO databases using variants and combinations of the keywords early life adversity, pregnancy, hypothalamic-pituitary-adrenal axis, and cortisol. STUDY SELECTION: We selected articles that included pregnant participants, included measures of cortisol and early life adversity, were published in English in a peer-reviewed journal, and were of sufficient methodologic quality. Date of publication was unrestricted through May 2020. DATA EXTRACTION: Twenty-five articles met the inclusion criteria and were evaluated for quality and risk of bias. Sources of cortisol included saliva, hair, plasma, and amniotic fluid. DATA SYNTHESIS: We categorized findings according to four physiologically distinct cortisol output parameters: diurnal (daily pattern), phasic (in response to an acute stressor), tonic (baseline level), and pregnancy-related change. Preliminary evidence suggests that early adversity may be associated with elevated cortisol awakening response (diurnal) and blunted response to acute stressors (phasic), irrespective of other psychosocial symptoms or current stress. For women with high levels of current stress or psychological symptoms, early adversity was associated with higher baseline (tonic) cortisol levels. CONCLUSION: Early life adversity in women is linked with alterations in cortisol regulation that are apparent during pregnancy. Researchers should examine how variations in each cortisol parameter differentially predict pregnancy health risk behaviors, maternal mental health, and neonatal health outcomes.

Stage 4S Neuroblastoma: What Are the Outcomes? A Systematic Review of Published Studies.

INTRODUCTION: The prognosis of stage 4S/MS neuroblastoma has traditionally been reported as excellent, yet conflicting treatment protocols exist for this enigmatic disease. To critically address this question, we have undertaken a systematic review of published studies to accurately determine outcomes for infants with stage 4S/MS neuroblastoma. MATERIALS AND METHODS: Studies were identified using MEDLINE, Embase, and Cochrane databases using the relevant search terms. Literature reviews, case reports, and adult studies were excluded. Data were extracted independently following article selection by three authors and reviewed by the senior author. RESULTS: The original search retrieved 2,325 articles. Following application of exclusion criteria and removing duplicate data, 37 studies (1,105 patients) were included for final review. Overall patient survival was 84%. Twelve studies (544 patients) recorded MYCN status. Mortality in MYCN amplified tumors was 56%. Chromosome 1p/11q status was reported in four studies and 1p/11q deletion carried a 40% fatality rate. Management included observation only (201 patients, 8.5% mortality), surgical resection of primary tumor only (153 patients, 6.5% mortality), chemotherapy only (186 patients, 21% mortality), radiotherapy (5 deaths, 33% mortality), chemotherapy with surgery (160 patients, 10% mortality), surgery with radiotherapy (21 patients, 19% mortality), radiotherapy with chemotherapy (42 patients, 29% mortality), and surgery with chemotherapy and radiotherapy (27 patients, 33% mortality). CONCLUSION: There is a significant mortality observed in stage 4S/MS neuroblastoma infants with a dismal outcome observed in those patients with MYCN amplification and 1p/11q deletion. Those patients suitably amenable for conservative management or surgery to excise the primary tumor carry the best prognosis.

Early life adversity and depressive symptoms predict cortisol in pregnancy.

Evidence suggests that exposure to early life adversity (ELA) programs the hypothalamic-pituitary-adrenal (HPA) axis to influence responses to later adversity and predisposes women to depression. However, few studies have examined whether ELA moderates the HPA cortisol response to adulthood adversity and depressive symptoms in pregnant women. The aims of this study were to determine (a) whether ELA, adulthood adversity, and depressive symptoms differentially predict patterns of cortisol and (b) whether ELA moderates the relationship of adulthood adversity or depressive symptoms to cortisol. This was a descriptive, cross-sectional study of pregnant women (N = 58, mean = 26.5 weeks gestation). Participants completed the Stress and Adversity Inventory and Edinburgh Depression Scale and collected salivary cortisol five times per day for 3 days to assess cortisol awakening response (CAR), diurnal cortisol slope, and cortisol area under the curve (AUC). ELA predicted a larger CAR, while depressive symptoms predicted a blunted CAR and higher cortisol AUC. Adulthood adversity predicted a blunted CAR and steeper diurnal slope, but only in women with high ELA. ELA also moderated the effect of depressive symptoms on diurnal slope. Early adversity and depressive symptoms appear to have significant effects on the HPA axis during pregnancy, with early adversity also moderating effects of depressive symptoms and adulthood adversity on cortisol regulation. Early adversity may be an important factor in identifying unique HPA phenotypes and risk for HPA axis dysregulation in pregnancy.

Psychiatric-Mental Health Nursing: Data-Driven Policy Platform for a Psychiatric Mental Health Care Workforce.

OBJECTIVE: To describe the development of a data-driven policy platform for psychiatric nurses roles and outcomes to alleviate the current mental health crisis in the United States. METHOD: Drawing on census data, statistical reports, and analysis of the current psychiatric mental health nursing (PMHN) workforce, a data-driven policy platform is designed to recruit, train, and prepare psychiatric nurses for addressing the nation's mental health crises. RESULTS: As noted by the Institute of Medicine's 2010 & 2016 reports on the future of nursing, the largest available health care workforce is not being used effectively, particularly to address the nation's mental health care needs. The development of a data-driven platform provides direction for psychiatric nurses in developing the workforce to meet the national mental health crisis. CONCLUSIONS: From education through practice and research, psychiatric-mental health nursing must build and share a data-driven, relationship-to-care platform emphasizing how PMHN care affects patient outcomes. Using a data-based platform to grow supportive public opinion, psychiatric mental health nursing can build a workforce to modify national accreditation standards and laws supporting data-driven PMHN care. The specialty profession must also seek to modify the nursing profession's attitude toward embracing data-driven platform of care relationships to psychiatric mental health outcomes.

Advancing Racial/Ethnic and Cultural Sensitivity Among PMHNP Students Through Education, Practice, and Experience.

BACKGROUND: There is an increased need for mental health providers to be more attuned to behavioral health needs of racial/ethnic/cultural minorities and the role of social milieus. AIMS: We prioritized training and assessing racial/ethnic and cultural sensitivity among psychiatric mental health nurse practitioner students throughout coursework, clinical practice, and experiences in underserved settings. METHOD: Prior to beginning clinical coursework, students completed a course on culturally competent care where we measured their (n = 26) perception of their ability to be racially/ethnically sensitive providers at the beginning and end of the semester, demonstrating significant improvement. During clinical coursework, preceptors measured students' racially/ethnically and culturally sensitive clinical behaviors with patients. RESULTS: Sensitivity of students in clinical training significantly improved over a semester of clinical supervision. Our results indicated that placements in underserved settings improved students' racial/ethnic/cultural sensitivity but only among advanced students. At final evaluation, advanced students in underserved settings self-reported significantly higher racial/ethnic and cultural sensitivity than students not in an underserved setting. CONCLUSIONS: Our data suggest that we can produce more racially/ethnically and culturally sensitivity providers through coursework, supervised clinical practice, and experiences in underserved settings. These data are preliminary, and we plan to follow up these results and replicate this work with other cohorts in future semesters.

A Systematic Review of Genetic Influence on Psychological Resilience.

When exposed to adversity, some individuals are at an increased risk of posttraumatic stress disorder, experiencing persistent biopsychosocial disturbances, whereas others adapt well, described as resilience. Resilience is a complex biopsychosocial phenomenon conceptualized as adaptation to adversity influenced by an individual's genetic variants, epistasis, epigenetics, and gene-by-environment interactions. Studies on psychological resilience have focused on behavioral and psychosocial variables with far less examination of the genetic contributions. The purpose of this review is to identify specific genetic variants contributing to the biological capacity for psychological resilience. PubMed and PsycINFO were searched using the following key words: psychological resilience AND genotype(s). Additional articles were identified from the Human Genome Epidemiology Navigator using the term resilience, psychological. Ten studies met the criteria. Six genes were empirically associated with psychological resilience: serotonin-transporter-linked polymorphic region ( 5-HTTLPR), dopamine receptor D4, brain-derived neurotrophic factor ( BDNF), corticotropin-releasing hormone receptor 1, oxytocin receptor and regulator of G-protein signaling 2 . The findings of this systematic review suggest that the L/L or L'/L' genotype of 5-HTTLPR and rs25531 in children/adolescents and the S/S or S'/S' genotype in adults are most frequently related to resilience. Additionally, the Val/Val genotype of rs6265 in BDNF in Caucasians was also associated with resilience. There are numerous factors contributing to the complexity of determining the genetic influence on resilience including analysis of rs25531, assumptions of the mode of inheritance, operationalization of resilience, demographic and population characteristics, sample size, and other types of genetic influence including epistasis and epigenetics. While current evidence is supportive, further investigation of the genetic influence on resilience is required.

TeleMental Health: Standards, Reimbursement, and Interstate Practice [Formula: see text].

BACKGROUND: TeleMental Health (TMH) is gaining widespread acceptance in the United States. OBJECTIVE: Summarize current evidence regarding TMH risks and benefits, standards of care, practice guidelines, reimbursement, and interstate practice issues pertinent to psychiatric nurses and consumers. DESIGN: A targeted review of literature, current practice, and TMH websites was generated using the following key search words: clinical outcomes, practice guidelines, regulations, interstate practice, and reimbursement for TMH. A search of government and professional organization websites and a literature review of PubMed and PsychINFO databases was limited to the past 15 years. RESULTS: Studies demonstrate TMH services are equal in efficacy to that provided in face-to-face encounters and preferred by some populations. Current TMH practice guidelines, reimbursement, and regulatory issues are reviewed. CONCLUSIONS: Providers, including psychiatric advanced practice registered nurses, can use TMH to effectively address the growing need for mental health services, although regulatory, licensure, and clinical issues must be addressed prior to offering TMH services.

A Concept Analysis of Resilience Integrating Genetics.

Although clinicians and researchers are interested in the phenomenon of resilience, there is no agreed-upon definition of resilience. Scientific evidence suggests that resilience is influenced by intrapersonal (e.g. personality traits) and environmental (e.g. social support) variables. A concept analysis was conducted to better understand the meaning of resilience. In this analysis, the antecedent of resilience was a potentially traumatic event; the defining attributes were ego-resiliency, emotion regulation, social support, and heredity; and the consequences were none to mild psychopathological symptoms and positive adaptation. This analysis can help nurses better understand resilience and its relationships to both intrapersonal and environmental variables.

Evidence-based practice: a model for clinical application.

Health care reform authorized by the Affordable Care Act is based on the belief that evidence-based practice (EBP) generates cost savings due to the delivery of more effective care. Published meta-analyses and systematic reviews provide clear, unbiased evidence on the effectiveness of specific interventions. Yet translating the interventions into the practice setting requires additional clinical skills and judgments extending beyond the scientific assessment of the EBP literature. Effective use of EBP interventions requires clinicians effectively answering an additional set of questions specific to the case and clinical context. These questions focus on correctly identifying the problem and increased level of specificity for any given situation. Using a clinical application of the PICO model, the clinician and the patient should be able to achieve a higher level of clinical outcomes.

Evidence-based practice principles: using the highest level when evidence is limited.

Clinicians providing psychiatric care are often faced with selecting interventions in areas of care for which there is limited scientific support, such as the information on traumatic stress responses and integrated care interventions. If they adhere to the principles of evidence-based practice (EBP), the lack of scientific support should not hamper clinicians from implementing the best EBP intervention. EBP interventions can be drawn from the literature provided clinicians accurately appraise the level of existing scientific knowledge. Regardless of the level of evidence, clinicians must discuss the recommended intervention, risks, benefits, and alternatives to achieve the best EBP outcome.

Challenges and opportunities in a tuberculosis outbreak investigation in southern Mississippi, 2005-2007.

OBJECTIVE: Between December 2005 and November 2007, a cluster of 11 tuberculosis (TB) cases emerged in Jackson County, Mississippi. We investigated the potential sources of disease transmission and epidemiologic links in this cluster to prevent future transmission in the community. MATERIALS AND METHODS: Cases of TB reported in Jackson County from December 2005 to November 2007 having matching genotypes or social links to patients with matching genotypes were included in the investigation. We interviewed patients, reviewed medical records, and performed contact investigations. RESULTS: The combined genotyping and epidemiologic data pointed to ongoing TB transmission in this rural community. A combination of patient-specific and programmatic factors, including substance use, delays in TB diagnosis, nonadherence, and TB program staffing cuts, contributed to this outbreak in the context of the 2004 and 2005 Atlantic hurricane seasons. CONCLUSIONS: To eliminate Mycobacterium tuberculosis transmission in this setting, recommendations for the TB program include enhanced coordination with substance abuse programs, community and provider education, and increased outreach capacity.

Evidence-based practice problems: form and focus.

Health care reform poses major challenges for psychiatric mental health care. Foremost among the challenges is a mandate for reimbursement based on performance-based outcomes. Clinicians can increase the efficiency of evidence-based practice searches by using the correct form of PICOT (population, intervention, comparator, outcome, time frame) question to focus the search, based on (a) diagnosis, (b) treatment, (c) prognosis, (d) etiology, (e) prevention, and (f) meaning. The correct form of a PICOT question focuses the literature search by requiring a minimum of sorting to find relevant studies. Quickly and effectively locating the critical evidence will help meet the performance standard mandates required by new health care reform legislation.