Children's Sleep and Mental Health During the COVID-19 Pandemic.

PURPOSE OF REVIEW: The COVID-19 pandemic and protracted home confinement required adjustments to schedules and routines generating concern about children's sleep. This review describes general considerations regarding children's sleep, changes and disturbances in their sleep during the pandemic, and the association of sleep measures with health and psychological outcomes in general and in the context of the pandemic. RECENT FINDINGS: A number of studies found an increase in the duration of children's sleep with later bedtimes and waketimes for some children. The research also documented sleep disturbances and associations between children's sleep and psychological outcomes. The extent to which increased sleep duration and changed sleep behaviors translated into improved sleep quality and/or a change in sleep disturbances remains unclear. This review suggests the importance of considering children's sleep in other mass trauma situations including, for example, natural and man-made disasters, as well as pandemics.

Inconclusive Findings in Studies of the Link Between Media Coverage of Mass Trauma and Depression in Children.

PURPOSE OF REVIEW: This paper reports a review of the empirical research examining the association between mass trauma media contact and depression in children, the factors that may influence the association, and the difficulties encountered in the study of media effects on depression. RECENT FINDINGS: All of the included studies assessed general population samples. Pre-COVID-19 research focused primarily on television coverage alone or on multiple media forms including television, while COVID-19 media studies examined various media forms including social media. Most studies used cross-sectional design and non-probability sampling. The review revealed inconclusive findings across studies. The study of mass trauma media effects on depression in children is complicated by a number of potential confounding factors and by the relatively high prevalence of depression in the general population. Media contact was a relatively minor consideration among other interests in the extant studies which failed to explore numerous issues that warrant attention in future research.

Children's Reactions to Media Coverage of War.

PURPOSE OF REVIEW: This paper reviews research on the effects of contact with war media coverage on psychological outcomes in children. RECENT FINDINGS: Children's contact with media coverage of war is pervasive and is associated with numerous outcomes and with their parents' reactions. Younger children are more affected by news stories with visual cues, while older children are more distressed by stories about actual threat. There is a strong theoretical basis for developmental influences on children's war media reactions, but the potential influence of other child factors (e.g., gender, socioeconomic disadvantage, prior trauma, culture, religious and political ideology) and aspects of coverage and the context of contact warrant additional attention. More research also is needed to explore differential effects of media coverage on children with different war exposures, the strategies children use to cope with coverage, and the mediating effects of parental involvement and intervention.

Terrorism Media Effects in Youth Exposed to Chronic Threat and Conflict in Israel.

PURPOSE OF REVIEW: This paper reviews the extant research on the effects of contact with terrorism media coverage on psychological outcomes in youth in the context of chronic threat and conflict in Israel. RECENT FINDINGS: The extant research is inconclusive with respect to the relationship between media contact and a variety of psychological outcomes in Israeli studies of youth exposed to ongoing threat and repeated terrorist attacks. Additional research is needed to examine potential differences in outcomes and the factors that influence youth coping and adaptation in an environment of chronic threat and extensive media coverage. Moreover, studies are needed to identify and evaluate potential parental, professional, and social strategies to enhance youth adjustment. Because political conflict in Israel is not likely to abate in the near future, the setting is ideal to conduct methodologically rigorous research including research using representative samples, prospective reporting, and longitudinal design.

Media Effects in Youth Exposed to Terrorist Incidents: a Historical Perspective.

PURPOSE OF REVIEW: This paper reviews the evidence on the relationship between contact with media coverage of terrorist incidents and psychological outcomes in children and adolescents while tracing the evolution in research methodology. RECENT FINDINGS: Studies of recent events in the USA have moved from correlational cross-sectional studies examining primarily television coverage and posttraumatic stress reactions to longitudinal studies that address multiple media forms and a range of psychological outcomes including depression and anxiety. Studies of events in the USA-the 1995 Oklahoma City bombing, the September 11 attacks, and the 2013 Boston Marathon bombing-and elsewhere have used increasingly sophisticated research methods to document a relationship between contact with various media forms and adverse psychological outcomes in children with different event exposures. Although adverse outcomes are associated with reports of greater contact with terrorism coverage in cross-sectional studies, there is insufficient evidence at this time to assume a causal relationship. Additional research is needed to investigate a host of issues such as newer media forms, high-risk populations, and contextual factors.

Do Direct Survivors of Terrorism Remaining in the Disaster Community Show Better Long-Term Outcome than Survivors Who Relocate?

Little is known about whether, compared to terrorism survivors who relocated to another area, better long-term outcome occurs in terrorism survivors who remain in the community, which may offer social support and formal services as well as ongoing trauma reminders and adversities. A cross-sectional telephone survey of OKC bombing survivors 19 years later assessed current symptoms of PTSD, anxiety and depression; posttraumatic growth; life satisfaction; medical conditions; alcohol use and smoking. We interviewed 138 survivors-114 (82.6%) remaining in OKC area and 24 (17.4%) relocated. Remaining survivors had higher PTS, anxiety and depression and lower posttraumatic growth scores than relocated survivors, and more remaining survivors disagreed with being satisfied with life, with differences not statistically significant. Groups did not differ in major medical problems except heart disease, not significantly different after adjusting for gender. Groups did not differ significantly in smoking or alcohol use. Contrary to expectations, remaining within the community after terrorism was not associated with better long-term psychological or medical outcome. Possible factors relevant to the literature are discussed.

Possible link of Interleukin-6 and Interleukin-2 with psychiatric diagnosis, ethnicity, disaster or BMI.

BACKGROUND: Cytokines are of increasing interest as markers for stress responses, mental disorders and general health. We assessed associations of two cytokines with several factors among relocated hurricane survivors and controls. METHODS: We examined 40 relocated hurricane survivors and 40 demographically matched (frequency matching) Oklahoma controls to assess relationships of Interleukin-2 (IL-2) and Interleukin-6 (IL-6) with psychiatric diagnoses (SCID-IV), demographic variables, hurricane exposure and body mass index (BMI). Participants were predominantly African American (n=70, 87.5%). RESULTS: Relocated Katrina survivors had higher proportions of current PTSD, major depression and psychiatric diagnoses than controls. Unexpectedly, exposure to Katrina with relocation was not by itself associated with differences in IL-2 or IL-6 levels. The mean IL-2 level was significantly higher in African American participants than other ethnicities (8 Caucasians, 2 Asians) and in those with a current psychiatric disorder. The mean IL-6 level was higher in females than males and in participants with any current psychiatric diagnosis. IL-6 level also correlated positively with participants' BMI. CONCLUSIONS: Results suggest that cytokines studied were influenced non-specifically by the presence of a mental disorder, and by demographic variables of gender, ethnicity and BMI. Implications of these findings are discussed, as well as possible long-term impact of the identified interleukin differences on immunologic, inflammatory, neuropsychiatric and other systems.

Reactions of Oklahoma City bombing survivors to media coverage of the September 11, 2001, attacks.

OBJECTIVE: This study explored the effects of media coverage of a terrorist incident in individuals remote from the location of a major attack who had directly experienced a prior terrorist incident. METHOD: Directly-exposed survivors of the 1995 Oklahoma City bombing, initially studied six months after the incident, and indirectly-affected Oklahoma City community residents were assessed two to seven months after the September 11, 2001, attacks. Survivors were assessed for a diagnosis of bombing-related posttraumatic stress disorder (PTSD) at index and follow up, and emotional reactions and September 11 media behavior were assessed in all participants. RESULTS: Among the three investigated forms of media (television, radio, and newspaper), only television viewing was associated with 9/11-related posttraumatic stress reactions. Exposure to the Oklahoma City bombing was associated with greater arousal in relation to the September 11 attacks, and among survivors, having developed bombing-related PTSD was associated with higher scores on all three September 11 posttraumatic stress response clusters (intrusion, avoidance, and arousal). Although time spent watching television coverage of the September 11 attacks and fear-related discontinuation of media contact were not associated with Oklahoma City bombing exposure, discontinuing September 11 media contact due to fear was associated with avoidance/numbing in the full sample and in the analysis restricted to the bombing survivors. CONCLUSION: Surviving a prior terrorist incident and developing PTSD in relation to that incident may predispose individuals to adverse reactions to media coverage of a future terrorist attack.

Intensely Exposed Oklahoma City Terrorism Survivors: Long-term Mental Health and Health Needs and Posttraumatic Growth.

In this study, we explore directly exposed terrorism survivors' mental health and health status, healthcare utilization, alcohol and tobacco use, and posttraumatic growth 18½ years postdisaster. Telephone surveys compared terrorism survivors and nonexposed community control subjects, using Hopkins Symptom Checklist, Breslau's PTSD screen, Posttraumatic Growth Inventory, and Health Status Questionnaire 12. Statistical analyses included multivariable logistic regression and linear modeling. Survivors, more than 80% injured, reported more anxiety and depression symptoms than did control subjects, with survivors' anxiety and depression associated with heavy drinking (≥5 drinks) and worse mental health and social functioning. While survivors had continued posttraumatic stress disorder symptoms (32 [23.2%] met probable posttraumatic stress disorder threshold), they also reported posttraumatic growth. Survivors had more care from physical, speech, respiratory, and occupational therapists. In this unprecedented long-term assessment, survivors' psychiatric symptoms, alcohol use, and ancillary health service utilization suggest unmet mental health and health needs. Extended recovery efforts might benefit from maximizing positive growth and coping.

Porphyria or Catatonia: Diagnostic Dilemma on the Medical Wards.

A 24-year-old Caucasian female, DD, was admitted to the medical service at an academic hospital with symptoms of weakness in bilateral lower extremities, falls, headaches, and altered mental status. Psychiatry was consulted to evaluate for psychiatric causes of her symptoms. This case presented a diagnostic challenge as the patient's identified symptoms changed almost daily, depending on what practitioner or medical service she encountered. In this study, we discuss the differential diagnoses, tests and treatments the patient received, with a review of literature helping differentiate between diagnostic parameters.

Priapism: What cause: mental illness, psychotropic medications or poly-substance abuse?

We present a case of priapism in a homeless patient with a psychiatric history of major depression, PTSD, polysubstance abuse (alcohol and cocaine) and past psychotropic medication use who was admitted to a local hospital for suicidal ideation. Priapism is a serious urological and a medical emergency which has often been associated with psychotropic medications (including the antidepressant trazodone), use of marijuana and alcohol, and other factors. This clinical case highlights the additive risks of medications and comorbid conditions in contributing to onset of priapism, emphasizing the importance of any pre-existing medical illness, diagnoses, and comorbid mental illnesses. Moreover, clinicians should consider potential side effects of all medications used and their drug interactions as they manage patients who develop this condition.

Do medical student stress, health, or quality of life foretell step 1 scores? A comparison of students in traditional and revised preclinical curricula.

THEORY: We explored the theory that measures of medical students' well-being and stress from different types of preclinical curricula are linked with performance on standardized assessment. HYPOTHESES: Self-reported stress and quality of life among sophomore medical students having different types of preclinical curricula will vary in their relationships to USMLE Step 1 scores. METHOD: Voluntary surveys in 2010 and 2011 compared self-reported stress, physical and mental health, and quality of life with Step 1 scores for beginning sophomore students in the final year of a traditional, discipline-based curriculum and the 1st year of a revised, systems-based curriculum with changed grading system. Wilcoxon rank sum tests and Spearman rank correlations were used to analyze data, significant at p <.05. RESULTS: New curriculum students reported worse physical health, subjective feelings, leisure activities, social relationships and morale, and more depressive symptoms and life stress than traditional curriculum students. However, among curriculum-related stressors, few differences emerged; revised curriculum sophomores reported less stress working with real and standardized patients than traditional students. There were no class differences in respondents' Step 1 scores. Among emotional and physical health measures, only feelings of morale correlated negatively with Step 1 performance. Revised curriculum students' Step 1 scores correlated negatively with stress from difficulty of coursework. CONCLUSIONS: Although revised curriculum students reported worse quality of life, general stress, and health and less stress from patient interactions than traditional students, few measures were associated with performance differences on Step 1. Moreover, curriculum type did not appear to either hinder or help students' Step 1 performance. To identify and help students at risk for academic problems, future assessments of correlates of Step 1 performance should be repeated after the new curriculum is well established, relating them also to performance on other standardized assessments of communication skills, professionalism, and later clinical evaluations in clerkships or internships.

Consultation Dilemma Catatonia in a Patient with Prior TBI: MentaI or Medical Disorder?

Mr. R, a 27 year old Hispanic male with history of traumatic brain injury (TBI) over ten years prior but no psychiatric history, presents to the psychiatric consultation service with recent onset of mutism, psychotic behavior and new diagnosis of epilepsy. The differential diagnosis is broad and includes both medical and psychiatric causes: post-ictal state, non-convulsive status epilepticus, delirium due to metabolic conditions, drugs, catatonia, conversion disorder, major depression with psychotic features, new onset schizophrenia or a combination of these possible diagnoses. We explore different medical causes that can present with symptoms of catatonia, as it is crucial to rule out a possible treatable medical cause.

A Practical Guide to Postoperative Delirium.

In conclusion, delirium is a common postoperative complication that especially impacts the elderly population. It contributes to a significant increase in morbidity, mortality, length of inpatient stay, and medical costs. Even with preventive efforts, many patients will develop postoperative delirium. While the gold standard treatment is to correct the underlying disorder, many therapies ranging from the use of antipsychotics to patient comfort measures are used to decrease the severity and duration of postoperative delirium. The most practical approach for physicians is continuous vigilance for the emergence of postoperative delirium. Movement toward increased use of multidisciplinary inpatient ward teams, early psychiatric consultation during postoperative delirium, larger clinical trials of prophylactic medications, and future research on delirium's pathogenesis will decrease complications of this common clinical problem.

Frontiers in Therapy of Treatment-Resistant-Depression: A Future Role of Ketamine?

Many patients treated for major depression in mental health and primary care settings fail to respond to adequate trials of available evidence-based treatments. Antidepressants, psychotherapy, and brain stimulation therapies have had some success, but many individuals do not respond to these treatments. Ketamine, a dissociative general anesthetic agent, is emerging as an unexpected possible future treatment to help individuals who suffer from refractory major depression.

Children of terrorism survivors: physiological reactions seven years following a terrorist incident.

OBJECTIVE: The aim of this study was to examine psychiatric illness and physiological indicators in the children of Oklahoma City bombing survivors seven years after the event. METHODS: A study of 17 Oklahoma City bombing survivors and their 21 adolescent and young-adult children conducted seven years after the disaster used structured diagnostic interviews to examine psychiatric outcomes. Physiological measurements included heart rate, systolic blood pressure, diastolic blood pressure, and physiological reactivity measured in response to a semi-structured bombing-reminder interview. RESULTS: Results revealed a statistically significant positive association between survivors and their children with respect to both post-disaster and current posttraumatic stress disorder (PTSD). Also, children whose parents met diagnostic criteria for either post-disaster or current major depression were more likely to meet criteria for a post-disaster behavior disorder and for any post-disaster psychiatric disorder than children whose parents did not meet criteria for post-disaster or current major depression. Survivors' children meeting criteria for any post-disaster psychiatric diagnosis had higher heart rates during the pre-test, test, and post-test periods than children who did not meet criteria for any disorder. Children whose survivor parents met criteria for bombing-related PTSD and for any post-disaster psychiatric disorder had greater heart rate reactivity than those whose parents did not. CONCLUSION: Findings of this study support previous literature on the relationships between children's psychiatric illness and physiological reactions and suggest interactions between disaster survivors' psychiatric illness and their children's psychiatric and physiological status.

Residents as teachers: psychiatry and family medicine residents' self-assessment of teaching knowledge, skills, and attitudes.

OBJECTIVE: Residents are one of the prime sources of information and education for medical students. As an initial step in supporting residents as teachers, a baseline self-assessment of residents' knowledge, skills, attitudes, and values related to teaching was conducted among psychiatry and family medicine residents to compare and improve their confidence and skills as teachers. METHOD: Psychiatry residents (N=12) and family medicine residents (N=23) completed self-assessments of their knowledge, skills, attitudes, and values related to teaching. Residents also were asked to list steps used in the One-Minute Preceptor process and estimate the time each spent in teaching. Descriptive summary statistics were used for four main areas related to teaching; t-test and chi-square analyses were conducted to ascertain whether there was a significant difference in resident groups. RESULTS: In the current study, the perceived amount of time spent for teaching patients was significantly higher among family practice residents, whereas no group differences were found for time teaching medical students, peers, community members, non-physicians, or others. However, family medicine residents rated themselves higher than psychiatry residents in their understanding of their roles in teaching medical students and teaching patients. Also, family medicine residents' self-reported teaching skills were more advanced (82.4%) than psychiatry residents' (54.2%). They most likely applied at least two different teaching methods in inpatient and outpatient settings, as compared with psychiatry residents. No significant group differences were found in the other 15 items assessing teaching knowledge, skills, attitudes, and values. CONCLUSION: Results indicate that residents' knowledge, skills, attitudes, and values regarding teaching varies across institutions and training programs. The psychiatry residents in this study do not clearly understand their role as educators with patients and medical students; they have a less clear understanding of teaching techniques, and report spending less time educating patients than do family medicine residents. The differences might be due to different patient populations and treatment settings. The study suggests that psychiatry residents may have difficulty adapting the One-Minute Preceptor technique in psychiatric settings. Results serve as a benchmarking study in a performance-improvement program to enhance psychiatry residents' teaching skills.

Psycho-oncology: a brief history and case study.

Ms. W. is a 55-year-old retired Caucasian woman who was diagnosed with esophageal cancer in October 2011. She underwent neoadjuvant chemotherapy with subsequent esophagectomy. She sought psychiatric help after receiving her cancer diagnosis. The field of psycho-oncology was developed to assist cancer patients and caregivers through their "cancer journey" from the time of diagnosis, throughout treatment and beyond. Criteria-defined psychiatric disorder, with adjustment disorder being the most common, is reported in approximately 33% to 50% of cancer patients. These realities have given psychiatry a role in the multi-disciplinary care approach in major cancer centers around the country. In this article, we describe the challenges faced by Ms. W. during her cancer diagnosis and provide a review of the literature in the emerging field of psycho-oncology and its role in the multidisciplinary care of cancer patients.

Emotional stress and heart rate variability measures associated with cardiovascular risk in relocated Katrina survivors.

OBJECTIVE: To explore the effects of hurricane exposure and forced relocation on the mind and body, we compared psychiatric diagnoses and symptoms with heart rate variability (HRV) for 34 relocated Katrina survivors and 34 demographically matched controls. METHODS: All participants were healthy and free of psychiatric and cardiovascular medications. We measured symptoms of posttraumatic stress disorder (PTSD) (Clinician-Administered PTSD Scale 1) and depression (Beck Depression Inventory), Axis I psychiatric diagnoses (Structured Clinical Interview for DSM-IV), psychosocial disability (Sheehan Disability Scale), and power spectral analysis HRV reactivity to trauma reminders. RESULTS: Katrina-related PTSD occurred in 38% of survivors and 12% of controls. Survivors reported higher levels of PTSD and depression symptoms, within diagnostic ranges, and greater psychosocial disability than controls. Survivors had higher resting heart rate (80.82 [standard deviation = 13.60] versus 74.85 [10.67], p = .05), lower parasympathetic (high-frequency [HF] normalized unit) baseline HRV activity (40.14 [23.81] versus 50.67 [19.93], p = .04) and less reactivity with trauma cues (-2.63 [20.70] versus -11.96 [15.84], p = .04), and higher baseline sympathovagal activity (low frequency/HF ratio) (2.84 [3.08] versus 1.35 [1.08], p = .04) than controls. Survivors with depression (n = 12) and with depression and PTSD combined (n = 7), but not those with PTSD (n = 13), had flattened parasympathetic responsiveness to trauma cues. HRV indices correlated with depressive (low frequency/HF, p = .01; HF normalized unit, p = .046) but not PTSD symptoms (p values > .05). CONCLUSIONS: Results showed this multilayer trauma's impact on emotional health and HRV-based measures of autonomic nervous system dysregulation. Specifically, dysregulation of depressed survivors' HRV in response to trauma reminders supports more autonomic involvement in traumatic loss/depression than in PTSD. Diagnostic criteria for PTSD include physiologic reactivity, and the present findings suggest that, in this setting, altered physiologic reactivity observed when PTSD coexists with depression.

Autonomic reactivity and hypothalamic pituitary adrenal axis dysregulation in spouses of Oklahoma City bombing survivors 7 years after the attack.

OBJECTIVE: The objective of this exploratory pilot study was to examine autonomic reactivity and hypothalamic pituitary adrenal axis dysregulation in spouses of highly exposed survivors of the 1995 Oklahoma City bombing. METHODS: This study compared psychiatric diagnoses and biological stress markers (physiological reactivity and cortisol measures) in spouses of bombing survivors and matched community participants. Spouses were recruited through bombing survivors who participated in prior studies. Individuals with medical illnesses and those taking psychotropic medications that would confound biological stress measures were excluded. The final sample included 15 spouses and 15 community participants. The primary outcome measures were psychiatric diagnoses assessed with the Diagnostic Interview Schedule for DSM-IV (DIS-IV). Biological stress markers were physiological reactivity and recovery in heart rate and blood pressure responses to a trauma interview and cortisol (morning, afternoon, and diurnal variation). RESULTS: Compared to the community participants, spouses evidenced greater reactivity in heart rate, systolic blood pressure, and diastolic blood pressure; delayed recovery in systolic blood pressure; and higher afternoon salivary cortisol. CONCLUSIONS: The results support the need for further research in this area to clarify post-disaster effects on biological stress measures in the spouses of survivors and the potential significance of these effects and to address the needs of this important population which may be overlooked in recovery efforts.