Adverse childhood experiences and prenatal depression in the maternal and development risks from environmental and social stressors pregnancy cohort.

The aim of this study was to examine the association between adverse childhood experiences (ACEs) and risk for depression among 480 predominantly low-income Hispanic/Latina women in the Maternal and Development Risks from Environmental and Social Stressors pregnancy cohort. Models were fitted to evaluate associations between ACEs and prenatal probable depression measured by the Center for Epidemiologic Studies-Depression Scale adjusting for recruitment site, age, income, race/ethnicity, marital status and parity. The ACEs Questionnaire parameterised experiences as counts (0-10), categories (0, 1-3 and 4+ ACEs) and domains. Participants had a significantly higher likelihood of prenatal probable depression per unit increase in ACEs count or if they reported 4+ ACEs relative to 0 ACEs. Higher likelihood of probable depression was also associated with higher counts of each ACEs domains: abuse, neglect and household dysfunction. Findings suggest systematic screening for depressive symptoms in those with a history of childhood adversities may be important in prenatal care practice.Impact StatementWhat is already known on this subject? Experiencing depression during pregnancy has been associated with later adverse maternal mental and physical health outcomes. Emerging studies indicate that adverse childhood experiences (ACEs) may maintain or increase the predisposition to prenatal depression.What do the results of this study add? Although prenatal depressive symptoms are prevalent among racial/ethnic minority samples including Hispanic/Latinas, research determining whether the association between ACEs and prenatal depression varies by nativity is scarce. Overall, ACEs were common among Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) participants and were associated with a higher likelihood of probable depression during pregnancy. These patterns did not significantly differ among the foreign-born versus U.S.-born Hispanic/Latina women, although the associations were stronger among U.S.-born Hispanic/Latina women.What are the implications of these findings for clinical practice and/or further research? Research should continue to focus on the effects of ACEs in communities that have been historically excluded in perinatal mental health services such as pregnant women from racial and ethnic minority groups. It may be important for clinicians to routinely screen for mental health during pregnancy as an adverse, psychological environment may impact both women and children. These findings suggest a need for improvement in systematic screening for depressive symptoms in those with a history of childhood adversities.

Perceived vulnerability to immigration policies among postpartum Hispanic/Latina women in the MADRES pregnancy cohort before and during the COVID-19 pandemic.

INTRODUCTION AND OBJECTIVES: Research suggests that perceived immigration policy vulnerability has important health implications. Coupled with the mental and physical stressors accompanying the postpartum period and a growing awareness of the discrimination and structural racism experienced by marginalized communities globally, the coronavirus disease 2019 period may have exacerbated stress among vulnerable populations, specifically postpartum Hispanic/Latina women. This study evaluated perceived immigration policy vulnerability (i.e. discrimination, social isolation, and family threats) in early postpartum Hispanic/Latina women in Los Angeles before and during the coronavirus disease 2019 pandemic. METHODS: The Perceived Immigration Policy Effects Scale (PIPES) was administered cross-sectionally at 1 month postpartum to 187 Hispanic/Latina women in the MADRES cohort. Respondents between September 2018 and March 2020 were classified as "pre-pandemic" (N = 128), between March 2020 and July 2020 as "early pandemic" (N = 38), and between August 2020 and November 2021 as "later pandemic" (N = 21). Average PIPES subscale scores were dichotomized into "higher" and "lower" groups (⩽median, >median) and logistic regression models were performed. RESULTS: Approximately half of participants had incomes of <$50,000 (50.3%) and were Latin American born (54.6%). After adjusting for age, nativity, education, income, postpartum distress, and employment status, early pandemic respondents had 5.05 times the odds of a higher score on the perceived discrimination subscale (95% CI: 1.81, 14.11), 6.47 times the odds of a higher score on the social isolation subscale (95% CI: 2.23, 18.74), 2.66 times the odds of a higher score on the family threats subscale (95% CI: 0.97, 7.32), and 3.36 times the odds of a higher total score (95% CI: 1.19, 9.51) when compared to pre-pandemic respondents. There were no significant subscale score differences between later pandemic and pre-pandemic periods. CONCLUSION: Higher perceived immigration policy vulnerability was reported among postpartum women during the early coronavirus disease 2019 pandemic versus pre-pandemic periods. This suggests greater social inequities during the early pandemic period.

Prenatal ambient air pollution and maternal depression at 12 months postpartum in the MADRES pregnancy cohort.

BACKGROUND: Depression is the leading cause of mental health-related morbidity and affects twice as many women as men. Hispanic/Latina women in the US have unique risk factors for depression and they have lower utilization of mental health care services. Identifying modifiable risk factors for maternal depression, such as ambient air pollution, is an urgent public health priority. We aimed to determine whether prenatal exposure to ambient air pollutants was associated with maternal depression at 12 months after childbirth. METHODS: One hundred eighty predominantly low-income Hispanic/Latina women participating in the ongoing MADRES cohort study in Los Angeles, CA were followed from early pregnancy through 12 months postpartum through a series of phone questionnaires and in-person study visits. Daily prenatal ambient pollutant estimates of nitrogen dioxide (NO2), ozone (O3), and particulate matter (PM10 and PM2.5) were assigned to participant residences using inverse-distance squared spatial interpolation from ambient monitoring data. Exposures were averaged for each trimester and across pregnancy. The primary outcome measure was maternal depression at 12 months postpartum, as reported on the 20-item Center for Epidemiologic Studies-Depression (CES-D) scale. We classified each participant as depressed (n = 29) or not depressed (n = 151) based on the suggested cutoff of 16 or above (possible scores range from 0 to 60) and fitted logistic regression models, adjusting for potential confounders. RESULTS: We found over a two-fold increased odds of depression at 12 months postpartum associated with second trimester NO2 exposure (OR = 2.63, 95% CI: 1.41-4.89) and pregnancy average NO2 (OR = 2.04, 95% CI: 1.13-3.69). Higher second trimester PM2.5 exposure also was associated with increased depression at 12 months postpartum (OR = 1.56, 95% CI: 1.01-2.42). The effect for second trimester PM10 was similar and was borderline significant (OR = 1.58, 95% CI: 0.97-2.56). CONCLUSIONS: In a low-income cohort consisting of primarily Hispanic/Latina women in urban Los Angeles, we found that prenatal ambient air pollution, especially mid-pregnancy NO2 and PM2.5, increased the risk of depression at 12 months after childbirth. These results underscore the need to better understand the contribution of modifiable environmental risk factors during potentially critical exposure periods.

Descriptions of depression and depression treatment in older Hispanic immigrants in a geriatric collaborative care program.

OBJECTIVES: To explore experiences with depression and depression treatment among older Hispanic immigrants participating in a collaborative care program of psychotherapy and antidepressant medication. METHOD: Semi-structured, in-depth interviews were conducted with 14 older Spanish-speaking Hispanic immigrants with major depression who participated in a collaborative care program within a public sector specialty geriatric clinic in Los Angeles, CA. RESULTS: Findings revealed that participants used various idioms to describe their experiences with depression, and that depression had a strong impact on functioning. Other findings indicated that depression was caused by various psychosocial problems, antidepressants were helpful in reducing depression, and that bilingual psychotherapists provided a welcoming and safe environment to express emotions and find solutions to problems. CONCLUSION: Results revealed participants' experiences with depression and the impact of participating in a collaborative care intervention for depression. Findings from this project should be used to inform future geriatric interventions for older Hispanic immigrants in the USA.

Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos.

OBJECTIVE: Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. METHODS: A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. RESULTS: Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001). CONCLUSIONS: Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.

Disclosure of Use and Abuse of Controlled Substances Among Psychiatric Outpatients.

BACKGROUND: Prescription drug abuse is a serious health concern and is considered a nationwide epidemic. Patients often fail or refuse to disclose the use of controlled substances, leaving prescribers and pharmacies unaware of the potential for harmful drug interactions and risk of overdose. Psychiatric patients are especially vulnerable to controlled substance misuse. OBJECTIVES: To determine hazardous patterns of prescription drug use among psychiatric outpatients and to raise awareness about the importance of reviewing information provided by prescription drug monitoring programs (PDMPs). METHODS: The medical records of 150 patients attending the Adult Outpatient Psychiatric Clinic at the Los Angeles County+University of Southern California (LAC+USC) Medical Center from July 2012 through May 2013 were reviewed. Patient activity reports were generated from California's PDMP. Nondisclosure of controlled substance use was identified by a discrepancy between patient reporting of prescriptions according to the medical records and PDMP reports. A "pattern suggestive of prescription drug abuse" was defined as having one or more of the following: within-class prescriptions from multiple providers and/or within-class early refills or within-class overlapping prescriptions picked up within 10 days of each other. RESULTS: Of the 150 patients, 113 were found in California's PDMP database. Of these 113 patients, 81 had obtained 111 prescriptions for controlled substances in the past 12 months. Of these 111 prescriptions, 52 (47%) were not disclosed to the primary psychiatrist, of which 14 (27%) revealed patterns consistent with prescription drug abuse. CONCLUSIONS: Reviewing PDMP databases before prescribing controlled substances should be considered a standard prescribing practice to prevent abuse, diversion, and adverse medical outcomes.

Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings?

Cognitive behavioral therapy (CBT), particularly when it includes an exposure component, is an empirically supported psychosocial treatment for anxiety disorders that has been shown to be highly efficacious, desirable to patients, and cost-effective. However, access to and receipt of exposure-based treatment CBT anxiety remains lacking despite these benefits. The current study reviewed electronic medical records at a large public outpatient psychiatry clinic in order to clarify what usual care for anxiety disorders entails, and to determine the extent to which effective psychosocial treatment is accessible to, and implemented with anxiety disorder patients. Database queries generated from the billing and medical record system at the Los Angeles County Adult Outpatient Psychiatry Clinic identified 582 patients presenting with an anxiety disorder diagnosis in a 6-month time frame. These patients' electronic medical records were reviewed using a standardized data collection form. Findings indicated that the majority of patients received pharmacological treatment for their anxiety. The majority of the psychosocial treatment delivered was supportive therapy. Among the minority of patients who did initiate CBT, an even smaller minority received treatment that included an exposure component, and those who did receive exposure likely received a sub-optimal dose. Understanding usual care delivery patterns is an important preliminary step to identifying and addressing barriers to optimal anxiety disorder treatment in adult community mental health settings.

Barriers to depression treatment among low-income, Latino emergency department patients.

Low-income and Latinos use the emergency department (ED) as a primary source of care. Also, the depression prevalence in ED patients is high, making the ED a compelling venue for depression screening and intervention. This study examined barriers and facilitators to depression treatment among low-income, predominantly Latino ED patients. We conducted telephone interviews with 24 ED patients (18-62 years of age, 79 % female) who dropped out of a depression treatment intervention. Using grounded theory, we analyzed perceptions of depression and treatment, and barriers and facilitators to mental health treatment. Although most patients acknowledged signs of depression, there was a lack of readiness to seek help. Patients reported negative perceptions about anti-depressant medication, even if they had no previous use. Barriers to treatment included transportation concerns, employment/unemployment, patient-provider issues, and immigrant documentation. Identified facilitators included consistent provider advice and "talking." This study introduced new misunderstanding and miscommunication barriers.

Racial-ethnic composition of provider practices and disparities in treatment of depression and anxiety, 2003-2007.

OBJECTIVES: This study explored whether racial and ethnic disparities in the treatment of depression and anxiety are associated with provider-level factors. METHODS: This study analyzed 58,826 office-based adult outpatient visits to primary care physicians and psychiatrists. Data were from the National Ambulatory Medical Care Survey, 2003-2007. Outcomes included counseling and referral for counseling, antidepressant prescription, and any care for depression or anxiety. The analyses of treatment outcomes were not limited to visits with a depression or anxiety diagnosis. RESULTS: Compared with visits to primary care physicians by whites, such visits by blacks and Hispanics were less likely to result in antidepressant prescription or in any care for depression or anxiety; primary care visits by Hispanics were also less likely to result in counseling. Compared with visits to psychiatrists by whites, such visits by blacks were less likely to result in an antidepressant prescription. The majority of visits to both primary care physicians and psychiatrists by blacks and Hispanics were to practices serving a high percentage of nonwhite patients. However, racial and ethnic disparities in care that were especially evident in primary care settings persisted after the analyses controlled for whether visits were to settings with a high or low percentage of nonwhite patients. CONCLUSIONS: Disparities in care for depression and anxiety in primary care continue and are not fully accounted for by less care being provided in settings that nonwhites frequent. Physician bias, resource issues, and patient factors may all play a role in the diagnosis and treatment of depression and anxiety.

Effectiveness of collaborative care in addressing depression treatment preferences among low-income Latinos.

OBJECTIVE: This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. METHODS: A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. RESULTS: The conjoint analysis preference survey showed that patients preferred counseling or counseling plus medication over antidepressant medication alone and that they preferred treatment in primary care over specialty mental health care, but they showed no significant preference for individual versus group treatment. Patients also indicated that individual education sessions, telephone sessions, transportation assistance, and family involvement were barrier reduction strategies that would enhance their likelihood of accepting treatment. Compared with patients assigned to usual care, those in the intervention group were 21 times as likely to receive preferred treatment. Among all participants, women, unemployed persons, those who spoke English, and those referred by providers were more likely to receive preferred treatment. CONCLUSIONS: Collaborative care interventions that include psychotherapy can increase the likelihood that Latino patients receive preferred care; however, special efforts may be needed to address preferences of working persons, men, and Spanish-speaking patients.

Efficiency in mental health practice and research.

Limited financial resources, escalating mental health-related costs and opportunities for capitalizing on advances in health information technologies have brought the theme of efficiency to the forefront of mental health services research and clinical practice. In this introductory article to the journal series stemming from the 20th NIMH Mental Health Services Research Conference, we first delineate the need for a new focus on efficiency in both research and clinical practice. Second, we provide preliminary definitions of efficiency for the field and discuss issues related to measurement. Finally, we explore the interface between efficiency in mental health services research and practice and the NIMH strategic objectives of developing improved interventions for diverse populations and enhancing the public health impact of research. Case examples illustrate how perspectives from dissemination and implementation research may be used to maximize efficiencies in the development and implementation of new service delivery models. Allowing findings from the dissemination and implementation field to permeate and inform clinical practice and research may facilitate more efficient development of interventions and enhance the public health impact of research.

Measuring Latinos' perceptions of depression: a confirmatory factor analysis of the Illness Perception Questionnaire.

This study examined the psychometric properties of the Revised Illness Perception Questionnaire adapted for a clinical sample of low-income Latinos suffering from depression. Participants (N = 339) were recruited from public primary care centers. Their average age was 49.73 years and the majority was foreign born females of either Mexican or Central American descent. Confirmatory factor analysis was used to test the factor structure of this measure. Construct and discriminant validity and internal consistency were evaluated. After the elimination of three items because of low factor loadings (< .40) and the specification of seven error covariances, a revised model composed of 24 items had adequate goodness-of-fit indices and factor loadings, supporting construct validity. Each of the subscales reported satisfactory internal consistency. Intercorrelations between the 5 illness perception factors provided initial support for the discriminant validity of these factors in the context of depression. The establishment of the psychometric properties of this adapted measure will pave the way for future studies examining the role illness perceptions play in the help seeking and management of depression among Latinos.

Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005.

CONTEXT: Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. OBJECTIVE: To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. DESIGN AND SETTING: Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995-2005 (n = 96,075). PARTICIPANTS: Visits to office-based primary care physicians and psychiatrists in the United States. MAIN OUTCOME MEASURES: Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. RESULTS: In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. CONCLUSIONS: Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.

Research issues for improving treatment of U.S. Hispanics with persistent mental disorders.

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Disparities in depression treatment for Latinos and site of care.

OBJECTIVE: This study examined the impact of patient characteristics and source of care on differences between whites and Latinos in use and quality of depression treatment in managed primary care settings. METHODS: Data were examined for 1,175 patients (398 Latinos and 777 whites) in 46 managed primary care practices who screened positive for probable depressive disorder. Patient baseline assessments were used to compile sociodemographic and clinical characteristics and to derive variables for receipt of any depression care and depression care that met minimum guidelines (antidepressant use or specialty counseling) in the past six months. Clinics were classified by the percentage of their patient population that consisted of Latinos to determine whether patients in highly Latino clinics reported lower rates of care. Predictors of use and quality of depression care were examined by using logistic regression. RESULTS: Rates of receipt of any depression care and guideline-level depression care were low, and Latinos were less than half as likely as whites to receive such care, even after the analyses controlled for independent predictors (that is, younger age, higher educational level, current unemployment, more comorbid medical illness, and a diagnosis of a depressive or anxiety disorder). The likelihood of receiving any care or care that met guidelines did not significantly vary according to whether clinics served a low, moderate, or high percentage of Latinos. CONCLUSIONS: Disparities in depression care for Latinos were not attributable to sociodemographic and clinical characteristics, and they were not attributable to receiving care in clinics that served ethnically similar or dissimilar clientele. These findings suggest that other patient or provider factors may be responsible.

Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer.

PURPOSE: To assess the prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer, receipt of antidepressant medications or counseling services, and correlates of depression. PATIENTS AND METHODS: Study patients were 472 women receiving cancer care in an urban public medical center. Women had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IIIB). A diagnostic depression screen and baseline questionnaire were administered before or during active treatment or during active follow-up. Self-report data were collected on receipt of depression treatment, use of supportive counseling, pain and receipt of pain medication, functional status and well-being, and perceived barriers to cancer care. RESULTS: Twenty-four percent of women reported moderate to severe levels of depressive disorder (30% of breast cancer patients and 17% of gynecologic cancer patients). Only 12% of women meeting criteria for major depression reported currently receiving medications for depression, and only 5% of women reported seeing a counselor or participating in a cancer support group. Neither cancer stage nor treatment status was correlated with depression. Primary diagnosis of breast cancer, younger age, greater functional impairment, poorer social and family well-being, anxiety, comorbid arthritis, and fears about treatment side effects were correlated with depression. CONCLUSION: Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.

Atypical psychotic symptoms in a Hispanic population: diagnostic dilemmas and implications for treatment.

OBJECTIVE: To better characterize psychotic symptoms and their treatment in Hispanic populations. DESIGN: Chart review. SETTING: Chelsea MGH Health Center and Chelsea Counseling Center (both affiliates of the Massachusetts General Hospital). PARTICIPANTS: Forty-four Hispanic patients presenting with psychotic symptoms in the context of mood and anxiety disorders. MEASUREMENTS: Chart review focussed on diagnosis, description, and cataloguing of psychotic symptoms and review of treatment efficacy. RESULTS: All but two patients described some atypical psychotic symptoms (e.g., doorbells or telephones ringing, voices of children, and visual hallucinations of animals or relatives). Treatment varied; 34 percent received monotherapy (either neuroleptic, antidepressant, or anxiolytic); 61 percent received polypharmacy; of these, 48 percent received a combination of antidepressant and anxiolytic; 19 percent received antidepressant with neuroleptic; 14 percent received antidepressant with neuroleptic and anxiolytic. No regimen was significantly better than any other. CONCLUSIONS: Psychotic symptoms in Hispanic patients have been noted anecdotally to present differently from those described in other populations. Our review appears to support this observation. Clinicians who work with Hispanic patients should ask about these atypical psychotic symptoms. We provide speculation on the nature of these symptoms, review approaches to treatment, and make recommendations for further investigation.