Treating insomnia improves depression, maladaptive thinking, and hyperarousal in postmenopausal women: comparing cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy, and sleep hygiene education.

INTRODUCTION: Depression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. Recent evidence supports the efficacy of cognitive-behavioral therapy for insomnia (CBTI) to treat menopausal insomnia, but it remains unclear whether treating insomnia also alleviates co-occurring depressive symptoms and depressogenic features. This trial tested whether CBTI improves depressive symptoms, maladaptive thinking, and somatic hyperarousal in postmenopausal women with insomnia; as well as whether sleep restriction therapy (SRT)-a single component of CBTI-is equally efficacious. MATERIALS AND METHODS: Single-site, randomized controlled trial. 117 postmenopausal women (56.34 ± 5.41 years) with peri-or-postmenopausal onset of chronic insomnia were randomized to three treatment conditions: sleep hygiene education control (SHE), SRT, and CBTI. Blinded assessments were performed at baseline, posttreatment, and six-month follow-up. RESULTS: CBTI produced moderate-to-large reductions in depressive symptoms, whereas SRT produced moderate reductions but not until six months posttreatment. Treatment effects on maladaptive thinking were mixed. CBTI and SRT both produced large improvements in dysfunctional beliefs about sleep, but weaker influences on presleep cognitive arousal, rumination, and worry. Presleep somatic arousal greatly improved in the CBTI group and moderately improved in the SRT group. Improvements in depression, maladaptive thinking, and hyperarousal were linked to improved sleep. SHE produced no durable treatment effects. CONCLUSIONS: CBTI and SRT reduce depressive symptoms, dysfunctional beliefs about sleep, and presleep somatic hyperarousal in postmenopausal women, with CBTI producing superior results. Despite its cognitive emphasis, cognitive arousal did not respond strongly or durably to CBTI. NAME: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov. REGISTRATION: NCT01933295.

Assessing Cognitive Representations of Antidepressants: Development and Validation of the Attitudes Toward Medication-Depression Inventory.

Antidepressant drugs represent the mainstay of treatment for depression; however, nonadherence is a major problem. Attitudes are predictors of long-term adherence and drive medication use. The Attitudes Toward Medication-Depression (ATM-D) Inventory was developed and tested with 131 patients in primary care settings who reported a diagnosis of depression. Content validity was assessed by experts with a 94.4% agreement on item relevancy. Exploratory factor analysis showed three factors (course of medication treatment, identity, and control) that accounted for 57% of the total variance in the final 17-item scale. The instrument demonstrated good internal consistency reliability (α = .76-.84) and test-retest reliability (α = .74-.83). Results support the construct validity and reliability of the instrument and revealed unique insights into patients' cognitive representations of their antidepressants. This study supported that patients have cognitive representations related to depression and antidepressants that go beyond simple concerns about the effects of the medication.

Exploratory Factor Analysis of the Strength of the Cultural Affiliation Scale.

BACKGROUND: Within the United States, there are individuals who retain the traditions and beliefs of cultural groups that vary from the general majority population. Both healthcare providers and researchers have reported that many individuals who live in but are less affiliated with the dominant culture tend to have less positive health outcomes. OBJECTIVE: The purpose of this study is to use factor analysis to assess the psychometric properties of Mood's 18-item Strength of Cultural Affiliation Scale (SCAS). METHODS: The SCAS was administered to 604 participants from a randomized clinical trial of cancer patients who were treated with radiotherapy at a large central city hospital located in the Midwest. RESULTS: Confirmatory Factor Analyses using Principal Component Analysis with Oblimin Rotation indicated a 16-item, 4-factor final solution with the following subscales: factor 1, lifestyle (7 items); factor 2, language and cultural-specific holidays (3 items); factor 3, relationships (4 items); and factor 4, cultural health practices (2 items). CONCLUSION: The SCAS demonstrated high reliability and content, construct, discriminant, convergent, divergent, and predictive validity. IMPLICATIONS FOR PRACTICE: The SCAS seems to be a reliable and valid tool for practitioners to use to assess a patient's strength of cultural affiliation to provide the best culturally sensitive care possible for the patient.

Considering a relational model for depression in Navy recruits.

OBJECTIVE: Key variables that have influenced depression in previous research were examined in this study including adult attachment, perceived social support, sense of belonging, conflict in relationships, and loneliness for their relationships in a relational model for depression with U.S. Navy recruits in basic training. METHODS: This theory-testing analysis study was part of a larger cross-sectional cohort study that examined the factors associated with depression in Navy recruits. The sample for this study included 443 recruits. Structural equation modeling was used to test the fit of the theoretical model. RESULTS: The proposed model explained 49% of the variance in depressive symptoms with loneliness and sense of belonging as the strongest indicators of depression. CONCLUSIONS: The Navy should consider interventions that increase sense of belonging in high risk for depression recruits to decrease loneliness and depression and circumvent recruits not completing basic training. The assumption that recruits are in close quarters and contact with other people and therefore are not lonely and receive adequate social support is not supported. This article contributes to advancing the science of mental health in relation to depression by considering predictors that are amenable to intervention.

Considering a Relational Model for Depression in Women with Postpartum Depression.

PURPOSE: To extend testing of a relational theory that a low sense of belonging, delayed or impaired bonding, and loneliness are salient risk factors for postpartum depression (PPD) in women. METHODS: Data for this theory-testing analysis came from a larger prospective longitudinal cohort study and included women who were retained to the end of the study at the 6 week postpartum interview (n=564). Structural equation modeling was used to test the "fit" of the model and determine significance of direct and indirect paths. RESULTS: The model explained 35% of the variance in postpartum depression with impaired bonding and loneliness as the strongest indicators. Lower sense of belonging, less perceived social support from a healthcare practitioner and a partner, and lower parenting sense of competence were additional predictors. CONCLUSION: Study findings challenge current thinking about the relationship between impaired bonding and PPD as this study raises the possibility that impaired bonding is a risk for PPD as opposed to the reverse relationship. The study provided evidence of the importance of healthcare practitioners' alliance with patients. This paper contributes to advancing the science of women's mental health in relation to depression by considering additional predictors which might be amenable to intervention.

Effects of parental alcoholism, sense of belonging, and resilience on depressive symptoms: a path model.

This paper explored the relationships between parental alcoholism, sense of belonging, resilience, and depressive symptoms among Koreans in the U.S. Data from 206 Koreans (Mean age = 28.4 years; 59.8% females) living in a Midwestern state were collected in 2009, using a web-based survey, which included Children of Alcoholic Screening Test, Sense of Belonging Instrument, Connor-Davidson Resilience Scale, and Beck Depression Inventory-II. Path analysis results revealed sense of belonging as the most powerful, and resilience as the second important factor, resisting depressive symptoms associated with parental alcoholism. Implications for practice and research and study limitations are discussed. The study's limitations are noted.

Psychometric testing of the decisional conflict scale: genetic testing hereditary breast and ovarian cancer.

BACKGROUND: : Hereditary breast and ovarian cancer (HBOC) syndrome is attributed mostly to mutations in the Breast Cancer 1 and Breast Cancer 2 genes (BRCA1/2). Mutation carriers of BRCA1/2 genes have significantly higher risk for developing breast cancer compared with the general population (55%-85% vs. 12%) and for developing ovarian cancer (20%-60% vs. 1.5%). The availability of genetic testing enables mutation carriers to make informed decisions about managing their cancer risk (e.g., risk-reducing surgery). However, uptake of testing for HBOC among high-risk individuals is low, indicating the need to better understand and measure the decisional conflict associated with this process. OBJECTIVE: : The aim of this study was to evaluate the reliability and validity of the modified Decisional Conflict Scale for use in decisions associated with genetic testing for HBOC. METHODS: : This cross-sectional cohort study, recruited women who pursued genetic testing for HBOC in two genetic risk assessment clinics affiliated with a large comprehensive cancer center and one of their female relatives who did not pursue testing. The final sample consisted of 342 women who completed all 16 items of the Decisional Conflict Scale. The psychometric properties of the scale were assessed using tests of reliability and validity, including face, content, construct, contrast, convergent, divergent, and predictive validity. RESULTS: : Factor analysis using principal axis factoring with oblimin rotation elicited a three-factor structure: (a) Lack of Knowledge About the Decision (α = .97), (b) Lack of Autonomy in Decision Making (α = .94), and (c) Lack of Confidence in Decision Making (α = .87). These factors explained 82% of the variance in decisional conflict about genetic testing. Cronbach's alpha coefficient was .96. DISCUSSION: : The instrument is an important tool for researchers and healthcare providers working with women at risk for HBOC who are deciding whether genetic testing is the right choice for them.

Design element alternatives for stress-management intervention websites.

Typical public and military-sponsored websites on stress and depression tend to be prescriptive. Some require users to complete lengthy questionnaires. Others reproduce printed flyers, papers, or educational materials not adapted for online use. Some websites require users to follow a prescribed path through the material. Stress Gym was developed as a first-level, evidence-based, website intervention to help U.S. military members learn how to manage mild to moderate stress and depressive symptoms using a self-help intervention with progress tracking and 24/7 availablility. It was designed using web-based, health-management intervention design elements that have been proven effective and users reported they prefer. These included interactivity, self-pacing, and pleasing aesthetics. Users learned how to manage stress by accessing modules they choose, and by practicing proven stress management strategies interactively immediately after login. Test results of Stress Gym with Navy members demonstrated that it was effective, with significant decreases in reported perceived stress levels from baseline to follow-up assessment. Stress Gym used design elements that may serve as a model for future websites to emulate and improve upon, and as a template against which to compare and contrast the design and functionality of future online, health-intervention websites.

Depressive symptomatology after mild-to-moderate traumatic brain injury: a comparison of three measures.

Measurement of posttraumatic brain injury depression is problematic. Disagreement exists about the best screening measure, and symptoms of brain injury often overlap those of depression. In an outpatient sample of 75 persons, we compared aspects of Criterion A of the Diagnostic and Statistical Manual of Mental Disorders--Fourth Revision, Text Revision (2000), with three depression subscales: the Neurobehavioral Functioning (NFI-D), Profile of Moods State (POMS-D), and Center for Epidemiologic Studies (CES-D). Nearly 40% of this outpatient sample had significant levels of depressive symptoms. All measures were internally consistent, reliable, and highly correlated. For persons with mild-to-moderate traumatic brain injury, the CES-D was the best screening instrument because of its ease in administration, sensitivity in detecting probable major depressive disorders, its established categories of severity, and its comprehensiveness. Further effort in the establishment of depression severity categories using the NFI-D is needed.

Chronic stress, sense of belonging, and depression among survivors of traumatic brain injury.

PURPOSE: To test whether chronic stress, interpersonal relatedness, and cognitive burden could explain depression after traumatic brain injury (TBI). DESIGN: A nonprobability sample of 75 mild-to-moderately injured TBI survivors and their significant others, were recruited from five TBI day-rehabilitation programs. All participants were within 2 years of the date of injury and were living in the community. METHODS: During face-to-face interviews, demographic information, and estimates of brain injury severity were obtained and participants completed a cognitive battery of tests of directed attention and short-term memory, responses to the Perceived Stress Scale, Interpersonal Relatedness Inventory, Sense of Belonging Instrument, Neurobehavioral Functioning Inventory, and Center for Epidemiological Studies Depression Scale;. FINDINGS: Chronic stress was significantly and positively related to post-TBI depression. Depression and postinjury sense of belonging were negatively related. Social support and results from the cognitive battery did not explain depression. CONCLUSIONS: Postinjury chronic stress and sense of belonging were strong predictors of postinjury depression and are variables amenable to interventions by nurses in community health, neurological centers, or rehabilitation clinics. Future studies are needed to examine how these variables change over time during the recovery process.