Predictive modeling of initiation and delayed mental health contact for depression.

BACKGROUND: Depression is prevalent among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, yet rates of Veteran mental health care utilization remain modest. The current study examined: factors in electronic health records (EHR) associated with lack of treatment initiation and treatment delay; the accuracy of regression and machine learning models to predict initiation of treatment. METHODS: We obtained data from the VA Corporate Data Warehouse (CDW). EHR data were extracted for 127,423 Veterans who deployed to Iraq/Afghanistan after 9/11 with a positive depression screen and a first depression diagnosis between 2001 and 2021. We also obtained 12-month pre-diagnosis and post-diagnosis patient data. Retrospective cohort analysis was employed to test if predictors can reliably differentiate patients who initiated, delayed, or received no mental health treatment associated with their depression diagnosis. RESULTS: 108,457 Veterans with depression, initiated depression-related care (55,492 Veterans delayed treatment beyond one month). Those who were male, without VA disability benefits, with a mild depression diagnosis, and had a history of psychotherapy were less likely to initiate treatment. Among those who initiated care, those with single and mild depression episodes at baseline, with either PTSD or who lacked comorbidities were more likely to delay treatment for depression. A history of mental health treatment, of an anxiety disorder, and a positive depression screen were each related to faster treatment initiation. Classification of patients was modest (ROC AUC = 0.59 95%CI = 0.586-0.602; machine learning F-measure = 0.46). CONCLUSIONS: Having VA disability benefits was the strongest predictor of treatment initiation after a depression diagnosis and a history of mental health treatment was the strongest predictor of delayed initiation of treatment. The complexity of the relationship between VA benefits and history of mental health care with treatment initiation after a depression diagnosis is further discussed. Modest classification accuracy with currently known predictors suggests the need to identify additional predictors of successful depression management.

Non-response to sad mood induction: implications for emotion research.

Experimental induction of sad mood states is a mainstay of laboratory research on affect and cognition, mood regulation, and mood disorders. Typically, the success of such mood manipulations is reported as a statistically significant pre- to post-induction change in the self-rated intensity of the target affect. The present commentary was motivated by an unexpected finding in one of our studies concerning the response rate to a well-validated sad mood induction. Using the customary statistical approach, we found a significant mean increase in self-rated sadness intensity with a moderate effect size, verifying the "success" of the mood induction. However, that "success" masked that, between one-fifth and about one-third of our samples (adolescents who had histories of childhood-onset major depressive disorder and healthy controls) reported absolutely no sadness in response to the mood induction procedure. We consider implications of our experience for emotion research by (1) commenting upon the typically overlooked phenomenon of nonresponse, (2) suggesting changes in reporting practices regarding mood induction success, and (3) outlining future directions to help scientists determine why some subjects do not respond to experimental mood induction.

Emotions in Depression: What Do We Really Know?

Major depressive disorder is among the most common and costly of all mental health conditions, and in the last 20 years, emotional dysfunction has been increasingly seen as central to depression. Accordingly, research on emotions in depression has proceeded with fury. The urgency of the work has tempted investigators to issue premature declarations and to sometimes overlook theoretical and methodological challenges entailed in studying emotion. I report on what we have learned thus far about how depression influences emotional reactivity and emotion regulation, and also carefully demarcate the vast terrain of what we do not yet know. Ironically, an attitude of humility may enable the field to achieve the ambitious but elusive goal of developing a rich, contextually specific account of depression-related changes in emotional reactivity and regulation. Such an account is a precondition for using knowledge about emotion to intervene more effectively to reduce depression's worldwide burden.

Positive autobiographical memory deficits in youth with depression histories and their never-depressed siblings.

OBJECTIVES: Impaired positive autobiographical memory (AM) is closely linked to emotional disorders. AM impairments are often found in depressed adults and may be related to the difficulties such persons have in regulating their dysphoric mood. By contrast, less is known about AM disturbances among adolescents, or about the functional relationship of AM disturbances to early-onset depression. DESIGN: A high-risk family design served to compare four groups of youth who differed in depression histories and familial depression risk. METHODS: Thirty-one currently depressed probands, 185 remitted probands, 204 never-depressed siblings of probands, and 180 healthy control youth were induced into a negative mood prior to recalling positive AMs via a novel memory elicitation procedure. Several positive AM characteristics were assessed. RESULTS: Relative to control youth, unaffected siblings and probands exhibited consistently impaired positive AMs. Moreover, we also found some evidence that probands were more impaired than siblings, who were in turn more impaired than controls, consistent with a gradient effect. CONCLUSIONS: Positive AM disturbances may not only precede the onset of depression in vulnerable youth, but also continue to persist after remission of a depressive episode. Clinical and basic research implications of the findings are discussed. PRACTITIONER POINTS: Positive AM impairments may be trait-like, persist in the euthymic phase of depression, and may serve as a risk marker for early-onset depression among vulnerable adolescents. Disturbances in positive AM may negatively impact the mood-regulatory functions of positive memory recall and contribute to persistent sadness and anhedonia, which are core features of depression. Our sample of currently depressed youth was relatively small, tempering our conclusions. Although we collected data on some important covariates (e.g., socioeconomic status), we lacked information on other relevant variables such as youths' executive functioning or IQ.

Turning quickly on myself: Automatic interpretation biases in dysphoria are self-referent.

Cognitive theories emphasise automatic interpretation biases (AIB) in the development and maintenance of depression. The current study examined AIB using the word sentence association paradigm for depression (WSAP-D) via endorsement rates and reaction time indices. We directly tested the importance of self-relevance for AIB by modifying the WASP-D task to include self-referent ambiguous stimuli and contrasting them with other-referent ambiguous stimuli. We hypothesised that the dysphoric group, but not the non-dysphoric group, would demonstrate AIB only for self-referent ambiguous stimuli. Consistent with our main hypotheses, dysphoric individuals endorsed negative interpretations more often and faster than non-dysphoric individuals, only for self-referent ambiguous stimuli. Self-relevance may be a critical aspect of AIB in dysphoric populations.

Why might poor sleep quality lead to depression? A role for emotion regulation.

Disordered sleep is strongly linked to future depression, but the reasons for this link are not well understood. This study tested one possibility - that poorer sleep impairs emotion regulation (ER), which over time leads to increased depressive symptoms. Our sample contained individuals with a wide range of depression symptoms (current depression, N = 54, remitted depression, N = 36, and healthy control, N = 53), who were followed clinically over six months and reassessed for changes in depressive symptom levels. As predicted, maladaptive ER mediated both cross-sectional and prospective relationships between poor sleep quality and depression symptoms. In contrast, an alternative mediator, physical activity levels, did not mediate the link between sleep quality and depression symptoms. Maladaptive ER may help explain why sleep difficulties contribute to depression symptoms; implications for interventions are discussed.

Sleep quality in healthy and mood-disordered persons predicts daily life emotional reactivity.

Disordered sleep has been linked to impaired emotional functioning in healthy and depressed individuals. Little is known, however, about how chronic sleep problems influence emotional reactivity in everyday life. Participants with major or minor unipolar depressive disorder (n = 60) and healthy controls (n = 35) reported on sleep and emotional responses to daily life events using a computerised Experience Sampling Method. We examined whether impaired sleep quality influenced emotional reactivity to daily events, and if this relationship was altered by unipolar mood disorders. Among healthy individuals, sleep difficulties were associated with enhanced negative affect (NA) to unpleasant events and a dulled response to neutral events. However, among mood-disordered persons, sleep difficulties were associated with higher NA across all types of everyday life events. Impaired sleep quality differentially affects daily life emotional reactions as a function of depression.

Familiality of mood repair responses among youth with and without histories of depression.

Affect regulation skills develop in the context of the family environment, wherein youths are influenced by their parents', and possibly their siblings', regulatory responses and styles. Regulatory responses to sadness (mood repair) that exacerbate or prolong dysphoria (maladaptive mood repair) may represent one way in which depression is transmitted within families. We examined self-reported adaptive and maladaptive mood repair responses across cognitive, social and behavioural domains in Hungarian 11- to 19-year-old youth and their parents. Offspring included 214 probands with a history of childhood-onset depressive disorder, 200 never depressed siblings and 161 control peers. Probands reported the most problematic mood repair responses, with siblings reporting more modest differences from controls. Mood repair responses of parents and their offspring, as well as within sib-pairs, were related, although results differed as a function of the regulatory response domain. Results demonstrate familiality of maladaptive and adaptive mood repair responses in multiple samples. These familial associations suggest that relationships with parents and siblings within families may impact the development of affect regulation in youth.

Cardiovascular recovery from psychological and physiological challenge and risk for adverse cardiovascular outcomes and all-cause mortality.

OBJECTIVE: Exaggerated cardiovascular (CV) reactivity to laboratory challenge has been shown to predict future CV morbidity and mortality. CV recovery has been less studied and has yielded inconsistent findings, possibly due to the presence of moderators. Reviews on the relationship between CV recovery and CV outcomes have been limited to cross-sectional studies and have not considered methodological factors. We performed a comprehensive meta-analytic review of the prospective literature investigating CV recovery to physical and psychological challenge and adverse CV outcomes. METHODS: We searched PsycINFO and PubMed for prospective studies investigating the relationship between CV recovery and adverse CV outcomes. Studies were coded for variables of interest and for effect sizes. We conducted a random-effects weighted meta-analysis. Moderators were examined with analysis of variance-analog and meta-regression analyses. RESULTS: Thirty-seven studies met the inclusion criteria (n = 125,386). Impaired recovery from a challenge predicted adverse CV outcomes (summary effect, r = 0.17, p < .001). Physical challenge was associated with larger predictive effects than psychological challenge. Moderator analyses revealed that recovery measured at 1 minute postexercise, passive recovery, use of mortality as an outcome measure, and older sample age were associated with larger effects. CONCLUSIONS: Poor recovery from laboratory challenges predicts adverse CV outcomes, with recovery from exercise serving as a particularly strong predictor of CV outcomes. The overall effect size for recovery and CV outcomes is similar to that observed for CV reactivity and suggests that the study of recovery may have incremental value for understanding adverse CV outcomes.

Mood repair via attention refocusing or recall of positive autobiographical memories by adolescents with pediatric-onset major depression.

BACKGROUND: Impaired emotion regulation is increasingly recognized as a core feature of depressive disorders. Indeed, currently and previously depressed adults both report greater problems in attenuating sadness (mood repair) in daily life than healthy controls. In contrast, studies of various strategies to attenuate sad affect have mostly found that currently or previously depressed adults and controls were similarly successful at mood repair in the laboratory. But few studies have examined mood repair among depression-prone youths or the effects of trait characteristics on mood repair outcomes in the laboratory. METHODS: Adolescents, whose first episode of major depressive disorder (MDD) had onset at age 9, on average (probands), and were either in remission or depressed, and control peers, watched a sad film clip. Then, they were instructed to engage in refocusing attention (distraction) or recalling happy memories. Using affect ratings provided by the youths, we tested two developmentally informed hypotheses about whether the subject groups would be similarly able to attenuate sadness via the two mood repair strategies. We also explored if self-reported habitual (trait) mood repair influenced laboratory performance. RESULTS: Contrary to expectations, attention refocusing and recall of happy memories led to comparable mood benefits across subjects. Control adolescents reported significantly greater reductions in sadness than did depressed (Cohen's d = .48) or remitted (Cohen's d = .32) probands, regardless of mood repair strategy, while currently depressed probands remained the saddest after mood repair. Habitual mood repair styles moderated the effects of instructed (state) mood repair in the laboratory. CONCLUSIONS: Whether depressed or in remission, adolescents with MDD histories are not as efficient at mood repair in the laboratory as controls. But proband-control group differences in mood repair outcomes were modest in scope, suggesting that the abilities that subserve affect regulation have been preserved in probands to some degree. Further information about the nature of mood repair problems among youths with depression histories would help to better understand the clinical course of MDD and to design personalized interventions for depression.

Reward learning in pediatric depression and anxiety: preliminary findings in a high-risk sample.

BACKGROUND: Reward learning has been postulated as a critical component of hedonic functioning that predicts depression risk. Reward learning deficits have been established in adults with current depressive disorders, but no prior studies have examined the relationship of reward learning and depression in children. The present study investigated reward learning as a function of familial depression risk and current diagnostic status in a pediatric sample. METHOD: The sample included 204 children of parents with a history of depression (n = 86 high-risk offspring) or parents with no history of major mental disorder (n = 118 low-risk offspring). Semistructured clinical interviews were used to establish current mental diagnoses in the children. A modified signal detection task was used for assessing reward learning. We tested whether reward learning was impaired in high-risk offspring relative to low-risk offspring. We also tested whether reward learning was impaired in children with current disorders known to blunt hedonic function (depression, social phobia, PTSD, GAD, n = 13) compared to children with no disorders and to a psychiatric comparison group with ADHD. RESULTS: High- and low-risk youth did not differ in reward learning. However, youth with current anhedonic disorders (depression, social phobia, PTSD, GAD) exhibited blunted reward learning relative to nondisordered youth and those with ADHD. CONCLUSIONS: Our results are a first demonstration that reward learning deficits are present among youth with disorders known to blunt anhedonic function and that these deficits have some degree of diagnostic specificity. We advocate for future studies to replicate and extend these preliminary findings.

Respiratory sinus arrhythmia reactivity in current and remitted major depressive disorder.

OBJECTIVE: Low resting respiratory sinus arrhythmia (RSA) levels and blunted RSA reactivity are thought to index impaired emotion regulation capacity. Major depressive disorder (MDD) has been associated with aberrant RSA reactivity and recovery to a speech stressor task relative to healthy controls. Whether impaired RSA functioning reflects aspects of the depressed mood state or a stable vulnerability marker for depression is unknown. METHODS: We compared resting RSA and RSA reactivity between adults with MDD (n = 49), remitted depression (RMD, n = 24), and healthy controls (n = 45). Electrocardiogram data were collected during a resting baseline, a paced-breathing baseline, and two reactivity tasks (speech stressor, cold exposure). RESULTS: A group by time quadratic effect emerged (F(2,109) = 4.36, p = .015) for RSA across phases of the speech stressor (baseline, instruction, preparation, speech, recovery). Follow-up analyses revealed that those with MDD uniquely exhibited blunted RSA reactivity, whereas RMD and controls both exhibited the anticipated task-related vagal withdrawal and posttask recovery. The group by time interaction remained after covariation for age, sex, waist circumference, physical activity, and respiration, but not sleep quality. CONCLUSIONS: These results provide new evidence that aberrant RSA reactivity marks features that track the depressed state, such as poor sleep, rather than a stable trait evident among asymptomatic persons.

The association between major depressive disorder in childhood and risk factors for cardiovascular disease in adolescence.

OBJECTIVE: Depression in adults is associated with risk factors for cardiovascular disease (CVD). It is unclear, however, when the association between clinical depression and cardiac risk factors develops or how early in life this association can be detected. METHODS: In an ongoing study of pediatric depression, we compared CVD risk factors including smoking, obesity, physical activity level, sedentary behavior, and parental history of CVD across three samples of adolescents: probands with established histories of childhood-onset major depressive disorder (n = 210), never-depressed siblings of probands (n = 195), and controls with no history of any major psychiatric disorder (n = 161). RESULTS: When assessed during adolescence, 85% of the probands were not in a major depressive episode. Nevertheless, at that assessment, probands had a higher prevalence of regular smoking (odds ratio [OR] = 12.54, 95% confidence interval [CI] = 4.36-36.12) and were less physically active than controls (OR = 0.59, CI = 0.43-0.81) and siblings (OR = 0.70, CI = 0.52-0.94) and had a higher rate of obesity than did controls (OR = 3.67, CI = 1.42-9.52). Parents of probands reported high rates of CVD (significantly higher than did parents of controls), including myocardial infarction and CVD-related hospitalization (ORs = 1.62-4.36, CIs = 1.03-15.40). Differences in CVD risk factors between probands and controls were independent of parental CVD. CONCLUSIONS: Major depression in childhood is associated with an unfavorable CVD risk profile in adolescence, and risks for pediatric depression and CVD may coincide in families. Effective prevention and treatment of childhood depression may be a means to reduce the incidence of adult CVD.

Atypical patterns of respiratory sinus arrhythmia index an endophenotype for depression.

Can atypical patterns of parasympathetic nervous system activity serve as endophenotypes for depression? Using respiratory sinus arrhythmia (RSA) as an index of parasympathetic nervous system function, we examined this question in two studies: one involving mothers with and without depression histories and their offspring (at high and low risk for depression, respectively), and a further study of adolescent sibling pairs concordant and discordant for major depression. In both studies, subjects were exposed to sad mood induction; subjects' RSA was monitored during rest periods and in response to the mood induction. We used Gottesman and Gould's (2003) criteria for an endophenotype and a priori defined "atypical" and "normative" RSA patterns (combinations of resting RSA and RSA reactivity). We found that atypical RSA patterns (a) predicted current depressive episodes and remission status among women with histories of juvenile onset depression and healthy controls, (b) predicted longitudinal trajectories of depressive symptoms among high- and low-risk young offspring, (c) were concordant across mothers and their juvenile offspring, (d) were more prevalent among never-depressed youth at high risk for depression than their low-risk peers, and (e) were more concordant across adolescent sibling pairs in which both versus only one had a history of major depression. Thus, the results support atypical RSA patterns as an endophenotype for depression. Possible mechanisms by which RSA patterns increase depression risk and their genetic contributors are discussed.

Parental depression confers greater prospective depression risk to females than males in emerging adulthood.

Females are at greater risk of depression than males, a pattern arising in adolescence and continuing in adulthood. One hypothesis is that major risk factors operate more robustly for females. We tested whether parental depression history imposes greater prospective depression risk for female emerging adults in a large community sample (ages 18-19, N = 637). Utilizing linear mixed regressions to model symptom changes over 2 years, we found the predictive utility of parental depression varied by gender. Females had higher depression symptoms overall, and those with parental depression remained at high levels throughout the adulthood transition, compared to at-risk males whose elevated symptoms decreased. This effect was specific to offspring depression (versus anxiety) and was found only for parental depression (versus other disorders). Female emerging adults with a parental depression history are at increased risk for future depression symptom elevations, which may partially explain their increased risk for depressive disorders in adulthood.

Social Motivation Differentiates Social Anxiety and Depression: A Daily Diary Study.

Because social anxiety and depression commonly co-occur, it can be challenging to disentangle the emotional and motivational features of these conditions in everyday life contexts. In this daily diary study, we sought to understand the interplay between daily social anxiety and depression symptoms and emotion and motivation, determining whether daily symptoms are independently linked with positive affect, negative affect, and social motivation (desire to approach or to withdraw from others). Community-dwelling adults (N = 269) with a wide range of social anxiety and depression symptoms completed daily assessments for 14 consecutive days (a total of 2,986 daily surveys). Within-person analyses found that increases in social anxiety and depression symptoms were uniquely associated with elevated negative affect; only increases in depression symptoms were associated with diminished positive affect. Increases in social anxiety symptoms were associated with an elevated desire to approach others but not a desire to withdraw from others. By contrast, increases in depression symptoms were associated with a diminished desire to approach others and an elevated desire to withdraw from others. Desire for social connection may distinguish social anxiety from depression. Examining patterns of daily social motivation may enhance clinicians' ability to differentiate the difficulties that arise from social anxiety from those that arise from depression.

Mental health treatment utilization patterns among 108,457 Afghanistan and Iraq veterans with depression.

People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Social anxiety and interpersonal risk for suicidal ideation: A longitudinal daily diary analysis.

INTRODUCTION: Social anxiety is associated with elevated suicidal ideation (SI). One potential explanation is that socially anxious persons experience frequent interpersonal stressors that elicit SI. Longitudinal designs with temporal ordering are needed to adequately test this hypothesis. Therefore, this study leveraged a longitudinal design combining trait and daily reports. METHODS: Two hundred eleven community adult participants with elevated levels of depression and/or social anxiety completed social anxiety and SI measures at baseline and again at a 1.5-month follow-up. Between these assessments, participants completed a 14-day diary study that assessed three forms of interpersonal distress: unfavorable social comparisons, perceived barriers to seeking social support, and loneliness. RESULTS: As predicted, simple mediation models revealed that baseline social anxiety had a significant indirect effect on SI severity at 1.5 months postbaseline via unfavorable social comparisons (indirect effect: ß = 0.07, p < 0.05) and barriers to seeking support (indirect effect: ß = 0.08, p < 0.05); however, social anxiety did not have a significant indirect effect on SI severity through loneliness. CONCLUSION: Study results are consistent with the proposition that increases in interpersonal distress may explain socially anxious persons' vulnerability to SI. Implications of these findings for the research, assessment, and treatment of suicidality in social anxiety are discussed.

Young Adult Mental Health Beyond the COVID-19 Era: Can Enlightened Policy Promote Long-Term Change?

The status of mental health for adolescents and young adults has aptly been termed a "crisis" across research, clinical, and policy quarters. Arguably, the status quo provision of mental health services for adolescents and young adults is neither acceptable nor salvageable in its current form. Instead, only a wholesale policy transformation of mental health sciences can address crises of this scope. Pandemic-related impacts on mental health, particularly among young adults, have clearly exposed the need for the mental healthcare field to develop a set of transformative priorities to achieve long overdue, systemic changes: (1) frequent mental health tracking, (2) increased access to mental health care, (3) working with and within communities, (4) collaboration across disciplines and stakeholders, (5) prevention-focused emphasis, (6) use of dimensional descriptions over categorical pronouncements, and (7) addressing systemic inequities. The pandemic required changes in mental healthcare that can and should be the beginning of long-needed reform, calling upon all mental health care disciplines to embrace innovation and relinquish outdated traditions.

Atypical development of resting respiratory sinus arrhythmia in children at high risk for depression.

Compromised respiratory sinus arrhythmia (RSA, i.e., low cardiac vagal control) frequently characterizes clinically depressed adults and also has been detected in infants of depressed mothers; however, its existence has not been established in older at-risk offspring. We investigated developmental patterns of RSA in a sample of 163 5- to 14-year-old children, who were either at high risk for depression (due to having a parent with a childhood-onset mood disorder) or low-risk for depression. We hypothesized that high-risk children have lower resting RSA than do low-risk children, which could reflect atypical developmental trajectories. Children's RSA was assessed during resting baseline periods on multiple occasions, typically 1-year apart. Linear growth modeling indicated a group by age interaction. Low-risk children (but not the high-risk children) exhibited a significantly increasing trajectory in resting RSA with age. Mood disorders in offspring did not account for the Group X Age interaction effect. Our study provides new evidence that children at high risk for depression have an atypical developmental trajectory of RSA across late childhood.