Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia's Public Mental Health Clinicians.

OBJECTIVE: Efforts to improve mental health treatment delivery come at a time of rising inequality and cuts or insufficient increases to mental health funding. Public mental health clinicians face increased demands, experience economic stress, and treat underresourced patients disproportionately burdened by trauma. The authors sought to understand clinicians' current economic and psychological conditions and the relationship of these conditions to the delivery of an evidence-based intervention (EBI) designed to treat posttraumatic stress disorder among youths. METHODS: In July 2020, 49 public mental health clinicians from 16 Philadelphia clinics who were trained in an EBI, trauma-focused cognitive-behavioral therapy (TF-CBT), were surveyed by e-mail. Respondents reported on their economic precarity, financial strain, burnout, secondary traumatic stress (i.e., the stress response associated with caring for people exposed to trauma), and TF-CBT use. Associations between clinicians' job-related stressors and their use of TF-CBT were examined with mixed models. Content coding was used to organize clinicians' open-ended responses to questions regarding financial strain related to the COVID-19 pandemic. RESULTS: Clinicians' economic precarity, financial strain, and job-related stress were high; 37% of clinicians were independent contractors, 44% of whom wanted a salaried position. Of 37 clinicians with education debt, 38% reported owing ≥$100,000. In the past year, 29% of clinicians reported lack of personal mental health care because of cost, and 22% met the cutoff for experiencing secondary traumatic stress symptoms. Education debt was negatively associated with use of TF-CBT (p<0.001). CONCLUSIONS: The stress of providing care in underresourced clinical settings may interfere with efforts to integrate scientific evidence into mental health care.

Associations between cortical thickness and reasoning differ by socioeconomic status in development.

Although lower socioeconomic status (SES) is generally negatively associated with performance on cognitive assessments, some children from lower-SES backgrounds perform as well as their peers from higher-SES backgrounds. Yet little research has examined whether the neural correlates of individual differences in cognition vary by SES. The current study explored whether relationships between cortical structure and fluid reasoning differ by SES in development. Fluid reasoning, a non-verbal component of IQ, is supported by a distributed frontoparietal network, with evidence for a specific role of rostrolateral prefrontal cortex (RLPFC). In a sample of 115 4-7-year old children, bilateral thickness of RLPFC differentially related to reasoning by SES: thicker bilateral RLPFC positively correlated with reasoning ability in children from lower-SES backgrounds, but not in children from higher-SES backgrounds. Similar results were found in an independent sample of 59 12-16-year old adolescents. Furthermore, young children from lower-SES backgrounds with strong reasoning skills were the only group to show a positive relationship between RLPFC thickness and age. In sum, we found that relationships between cortical thickness and cognition differ by SES during development.

Childhood socioeconomic status and executive function in childhood and beyond.

Socioeconomic status (SES) predicts health, wellbeing, and cognitive ability, including executive function (EF). A body of recent work has shown that childhood SES is positively related to EF, but it is not known whether this disparity grows, diminishes or holds steady over development, from childhood through adulthood. We examined the association between childhood SES and EF in a sample ranging from 9-25 years of age, with six canonical EF tasks. Analyzing all of the tasks together and in functionally defined groups, we found positive relations between SES and EF, and the relations did not vary by age. Analyzing the tasks separately, SES was positively associated with performance in some but not all EF measures, depending on the covariates used, again without varying by age. These results add to a growing body of evidence that childhood SES is associated with EF abilities, and contribute novel evidence concerning the persistence of this association into early adulthood.

Medicare Expenditure Correlates of Atrophy and Cerebrovascular Disease in Older Adults.

Background/Study Context: Magnetic resonance imaging (MRI) markers of cerebrovascular disease and atrophy are common in older adults and are associated with cognitive and medical burden. However, the extent to which they are related to health care expenditures has not been examined. We studied whether increased Medicare expenditures were associated with brain markers of atrophy and cerebrovascular disease in older adults. METHODS: A subset of participants (n = 592; mean age = 80 years; 66% women) from the Washington Heights Inwood Columbia Aging Project (WHICAP), a community-based observational study of aging in upper Manhattan, received high-resolution MRI and had Medicare expenditure data on file. We examined the relationship of common markers of cerebrovascular disease (i.e., white matter hyperintensities and presence of infarcts) and atrophy (i.e., whole brain and hippocampal volume) with Medicare expenditure data averaged over a 10-year period. Main outcome measures were (a) mean Medicare payment per year across the 10-year interval; (b) mean payment for outpatient care per year; and (c) mean payment for inpatient care per year of visit. In addition, we calculated the ratio of mean inpatient spending to mean outpatient spending as well as the ratio of mean inpatient spending to mean total Medicare spending. RESULTS: Increased Medicare spending was associated with higher white matter hyperintensity volume, presence of cerebral infarcts, and smaller total brain volume. When examining specific components of Medicare expenditures, we found that inpatient spending was strongly associated with white matter hyperintensity volume and that increased ratios of inpatient to outpatient and inpatient to total spending were associated with infarcts. CONCLUSION: Medicare costs are related to common markers of "silent" cerebrovascular disease and atrophy.