Demographic Predictors of Telehealth Use for Integrated Psychological Services in Primary Care During the COVID-19 Pandemic.

OBJECTIVE: Prior to the COVID-19 pandemic, growing mental health needs were well documented, particularly those of diverse patient populations. The current study aims to better understand racial and psychosocial factors associated with patient utilization of integrated psychological services via telehealth during the COVID-19 pandemic within a diverse primary care clinic. METHODS: Retrospective chart reviews were completed for patients seen by an integrated psychology team within a general internal medicine clinic at a large urban health system during the year 2020. Demographics were extracted from the medical record. Multivariate logistic regression analyses were conducted to examine demographic predictors for (1) telehealth video visits vs. audio only telehealth visits and (2) in-person vs. telehealth visits (both video and audio). RESULTS: Older patients, Black patients, and those with Medicare and Medicaid were more likely to complete audio only telehealth visits vs. video visits. There were no significant demographic predictors when comparing in-person vs. telehealth (both video and audio). DISCUSSION: Some underserved and vulnerable patient populations are more likely to utilize audio-only integrated psychological visits to video visits. The utilization of audio visits over video for certain demographics speaks to the need to better understand how this type of care may benefit psychological services in the future and continued advocacy to extend audio mental health visits beyond the public health emergency to address patient populations with significant mental health needs.

Utilizing Primary Care to Engage Patients on Opioids in a Psychological Intervention for Chronic Pain.

INTRODUCTION: Given the risks of opioids for pain management, we need nonpharmacological interventions that patients will engage in and that can reduce opioid use. The purpose was to examine whether offering a psychological intervention in primary care can engage patients receiving opioids for pain management and to explore whether the intervention influences opioid use. METHODS: This was a secondary analysis of a pilot randomized controlled trial (RCT) of a 5-session psychological intervention in primary care for chronic pain. Patients with chronic pain (N = 220) were approached to enroll in the RCT. Electronic health records were reviewed to determine whether patients were prescribed opioids or pain medications at the time they were approached about the RCT and the 6-months following the intervention. RESULTS: Enrollees and non-enrollees had similar rates of opioid prescriptions, morphine milligram equivalent dose of opioids, and rates of other pain medication prescriptions (p> .05). However, no males with an opioid prescription enrolled. Though not significant, those in the intervention had lower odds of having an opioid prescription 6 months following the intervention (p= .09, OR= .32). Those randomized to the intervention had lower odds of having a non-opioid pain medication prescription (p= .01, OR= .17). CONCLUSIONS: Having an opioid prescription did not interfere with enrollment, suggesting that primary care may be useful for engaging patients on opioids in a psychological treatment for chronic pain. However, this may be true for women, and not men. This intervention also showed promise for decreasing opioid use and warrants further study.

A brief psychological intervention for chronic pain in primary care: Examining long-term effects from a pilot randomized clinical trial.

BACKGROUND: Despite the existence of evidence-based psychological interventions for pain management, there are barriers that interfere with treatment engagement. A brief intervention integrated into primary care reduced barriers and showed promising benefits from pre- to post-intervention. However, it is unknown whether a brief intervention can provide long-term effects. The purpose of this study was to examine whether a brief psychological intervention offered benefits in pain severity, pain interference, pain catastrophizing, and depressive symptoms at 1- and 6-month follow-ups. METHODS: The majority of participants who enrolled in a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain in primary care completed the 1-month (n = 54; 90%) and 6-month follow-ups (n = 50; 83.3%). Participants completed measures of pain severity, pain interference, pain catastrophizing, and depressive symptoms. RESULTS: From baseline to the 6-month follow-up, those in the intervention group had significantly better outcomes for pain severity (p = 0.01) and pain catastrophizing (p = 0.003) compared with the control group. There were no significant differences between the intervention and control groups for pain interference and depression. The percentage of patients in the intervention experiencing clinically significant improvement across all outcomes was higher than the control group. CONCLUSIONS: Findings suggest that a brief psychological intervention for chronic pain in primary care may offer longer-term benefits similar to that of lengthier interventions. Future studies should examine this through a randomized clinical trial with a larger sample size.

Socioeconomic status, financial stress, and glucocorticoid resistance among youth with asthma: Testing the moderation effects of maternal involvement and warmth.

OBJECTIVES: Children who grow up in more socioeconomically disadvantaged homes experience greater levels of inflammation and worse asthma symptoms than children from more advantaged families. However, recent evidence suggests that certain family-level factors can mitigate health disparities associated with socioeconomic status (SES). In a sample of youth with asthma, we investigated the potential buffering effects of maternal involvement and warmth on SES disparities in asthma-related immune responses, assessed via glucocorticoid resistance (GR) of immune cells. METHODS: One hundred and forty-three youth (10-16 years of age) with asthma completed measures of maternal involvement and warmth, and their primary caregivers reported their levels of education, income, and financial stress. Peripheral blood mononuclear cells from youth's blood were isolated, cultured, and assayed to determine mitogen-stimulated (PMA/INO + Etho) and mitogen/hydrocortisone-stimulated (PMA/INO + Cort) levels of two Th-2 cytokines (i.e., interleukin-5, interleukin-13) and one Th-1 cytokine (i.e., interferon-γ). GR was calculated by subtracting log-transformed cytokine concentration in the PMA/INO + Etho samples from log-transformed cytokine concentration in the PMA/INO + Cort samples. RESULTS: Both maternal involvement and warmth moderated the indirect pathway from family SES to GR of Th-2 cytokines via financial stress. Specifically, we found that low family SES was associated with elevated GR of Th-2 cytokines via increased financial stress among youth reporting low levels of maternal involvement and warmth, but not among those reporting high levels of maternal involvement or warmth. CONCLUSIONS: These results highlight the protective role of maternal involvement and warmth in health-related biological processes modulated by family SES among youth with asthma.

A Brief Psychological Intervention for Chronic Pain in Primary Care: A Pilot Randomized Controlled Trial.

OBJECTIVE: Although evidence-based psychological interventions improve chronic pain, many patients do not engage in behavioral health services. Offering a brief intervention in a medical setting may provide benefits to patients with chronic pain. The purpose of this study was to examine preliminary outcomes of a brief psychological intervention for chronic pain delivered in primary care. DESIGN: Pilot randomized controlled trial. SETTING: Primary care clinic. SUBJECTS: Sixty participants with chronic pain were randomized to a 5-session psychological intervention or treatment-as-usual control group. METHODS: Participants completed pre- and post-intervention measures assessing pain severity, pain interference, pain catastrophizing, depression, and anxiety. RESULTS: Most participants (76.7%) randomized to the intervention completed all sessions. Compared to the control group, those in the intervention had decreases in pain severity (P = .048), pain catastrophizing (P = .04), and depression (P = .01) from pre- to post-intervention. Within the intervention group, there was a significant improvement in pain interference scores (P = 0.02). Within the intervention group, effect sizes were medium to large for changes in pain severity, pain interference, pain catastrophizing, and depression scores. There were no significant changes in anxiety scores. CONCLUSION: Results suggest that delivery of a brief psychological intervention for chronic pain in primary care appears to offer improvements in pain severity, pain interference, pain catastrophizing, and depression. Findings suggest that shorter-term psychological interventions may offer similar benefits as longer-term ones. Furthermore, offering a brief intervention in primary care may increase access and engagement in behavioral pain management services. Future research should examine this through a fully-powered trial with longer-term outcomes.

Motivating residents to change communication: the role of a brief motivational interviewing didactic.

INTRODUCTION: Motivational interviewing (MI) is a patient-centered approach that encourages patients to change behaviors. MI training programs have increased residents' knowledge and use of MI skills; however, many residency programs may not have the time to dedicate to lengthy MI programs. The purpose of this study was to evaluate the benefits of a brief MI didactic for residents in an academic internal medicine patient-centered medical home. METHODS: Thirty-two residents completed a 1-h MI training between October 2016 and June 2017 and completed measures on their knowledge of, confidence using, and utilization of MI skills prior to the training, immediately after the training, and at a 1-month follow-up. RESULTS: The residents' knowledge of and confidence using MI skills increased from pre-test to post-test and also increased from pre-test to the 1-month follow-up. CONCLUSION: The utilization of MI skills increased from pre-test to the 1-month follow-up. A 1-h didactic offers benefits to residents.

Why WAIT? Preliminary evaluation of the weight assistance and intervention techniques (WAIT) group.

Individuals who attempt to lose weight may struggle because they lack skills to address problematic eating behaviors. There are multiple programs that have taught patients some of these behavioral strategies; however, it is not clear which strategies patients find to be the most useful. The purpose of this study was to examine preliminary outcomes after completion of a six-week integrative group for weight management. Retrospective chart reviews were conducted of 51 patients who completed an integrative, psychological weight management group. Patients were mailed surveys 1-2 years after completion of the group assessing for current problematic eating behaviors (i.e. emotional eating and food addiction), satisfaction with treatment, and skills they continue to use. The majority of patients lost weight, were satisfied with the group, found the group to be helpful, and felt confident they could maintain behavior changes. The strategies patients most commonly continued to use post-group included mindful eating, keeping a food diary, carrying out an exercise plan, regular weigh-ins, and planning for social eating. The number of food addiction symptoms decreased from pre- to post-group. An integrative psychological weight management group may provide patients with skills and confidence to assist with managing problematic eating behaviors and weight loss.

Self-Disclosure and Perceived Responsiveness Among Youth With Asthma: Links to Affect and Anti-Inflammatory Gene Expression.

Self-disclosure and perceived responsiveness are important building blocks of social relationships that have long-lasting consequences for health and well-being. However, the conditions under which self-disclosure and responsiveness are likely to benefit health, and how early in life these benefits arise, remain unclear. Among 141 youth (aged 10-17) with asthma, we investigated how average daily levels of self-disclosure and responsiveness are linked to positive and negative affect and the expression of the glucocorticoid receptor gene NR3C1, a marker of improved regulation of stress physiology and immune functioning. Higher levels of self-disclosure were associated with higher NR3C1 expression and positive affect only when perceptions of responsiveness were high. Furthermore, perceived responsiveness was linked to NR3C1 expression for females but not males. These results suggest that the potential benefits of self-disclosure depend on the extent to which interaction partners are perceived as responsive and that these benefits emerge prior to adulthood.

Socioeconomic status, family negative emotional climate, and anti-inflammatory gene expression among youth with asthma.

The glucocorticoid receptor gene NR3C1 is an important down-regulator of inflammation and is typically under-expressed in individuals with low socioeconomic status (SES). Negative emotionality has been suggested as a potential mediator of SES disparities in health outcomes. In this study, we expand this literature by naturalistically assessing negative emotionality in a key emotional environment: the family. In a sample of 104 youth with asthma (10-17 years) and their primary caregiver, we assessed SES via caregiver report, emotional expression by youth and parents in the home over four days using the electronically activated recorder (EAR), and NR3C1 expression via blood collected from youth. Although there was not a direct effect of SES on NR3C1 expression, bootstrapping mediation analyses showed a significant indirect path such that lower SES was associated with a more negative family emotional climate, which in turn predicted reduced NR3C1 expression. No mediation effects were found for family positive emotional climate. This research demonstrates the importance of examining the effects of SES on emotion expression in the family context and suggests a critical biopsychosocial pathway underlying SES-based health disparities that may extend beyond youth.

Youth secrets are associated with poorer sleep and asthma symptoms via negative affect.

OBJECTIVE: Among older children and adolescents, keeping secrets from parents is consistently associated with lower levels of psychological well-being. Further, concealing one's thoughts and emotions has been associated with poor physical health outcomes in adults. However, it remains an open question whether secret-keeping is associated with poorer health and health-related behaviors (such as sleep) among youth and, if those hypothesized links exist, what the psychological mechanisms might be. We investigated the associations among youth secrecy towards parents, daily asthma symptoms and daily sleep behaviors in a sample of low-income youth with asthma aged 10-17 and tested negative affect as a possible mediator of these associations. METHODS: One hundred and seventy two youths reported the extent to which they kept secrets towards parents over a period of four days. Asthma symptoms, nighttime awakenings, sleep onset latency, and subjective sleep quality were assessed with daily diaries completed by youths. RESULTS: More frequent secret-keeping was associated with more severe asthma symptoms, lower ratings of sleep quality and greater number of nighttime awakenings. Secrecy was also associated with increased negative affect, which accounted for the associations between secrecy and number of awakenings and daytime asthma symptoms. These findings remained significant after controlling for youth age and other relevant demographic factors. CONCLUSIONS: Our findings suggest that secrecy towards parents can have consequential health outcomes for youth with asthma and point to the importance of investigating affective processes as mediators of the influence of secret-keeping on youth health.

Mothers' Attachment is Linked to their Children's Anti-Inflammatory Gene Expression via Maternal Warmth.

Research has demonstrated links between adult romantic attachment and one's own physical health; little is known about links between adult attachment orientations and offspring health. Prior work has shown that parents' greater attachment anxiety and avoidance predicts less warmth toward their children. Extensive work has also shown that lower maternal warmth has negative downstream effects on offspring health. We tested the novel hypothesis that mothers' dispositional romantic attachment would be linked-via maternal warmth-to their children's expression of the glucocorticoid receptor gene NR3C1, higher expression of which is associated with healthier stress-regulation and inflammatory response. In a sample of 132 youth with asthma, we found that mothers' attachment anxiety and avoidance were both negatively associated with children's expression of NR3C1, explained by lower youth-rated maternal warmth. Effects held after adjusting for demographic and psychosocial covariates. Implications for parents' attachment influencing the health of offspring are discussed.

Religious participation predicts diurnal cortisol profiles 10 years later via lower levels of religious struggle.

OBJECTIVE: Multiple aspects of religion have been linked with a variety of physical health outcomes; however, rarely have investigators attempted to empirically test the mechanisms through which religiosity impacts health. The links between religious participation, religious coping, and diurnal cortisol patterns over a 10-year period in a national sample of adults in the United States were investigated. METHOD: Participants included 1,470 respondents from the Midlife in the United States (MIDUS) study who provided reports on religious participation, religious coping, and diurnal cortisol. RESULTS: Religious participation predicted steeper ("healthier") cortisol slopes at the 10-year follow-up, controlling for potential confounds. Further, religious struggle (religious coping marked by tension and strain about religious and spiritual issues) mediated the prospective association between religious participation and cortisol slope, such that greater religious attendance predicted lower levels of religious struggle 10 years later, which in turn was linked with a steeper cortisol slope; this effect remained strong when controlling for general emotional coping and social support. Positive religious coping was unrelated to diurnal cortisol patterns. CONCLUSION: These findings identify religious struggle as a mechanism through which religious participation impacts diurnal cortisol levels and suggest that diurnal cortisol is a plausible pathway through which aspects of religion influence long-term physical health. (PsycINFO Database Record

Youth reports of parents' romantic relationship quality: Links to physical health.

OBJECTIVE: Prior work has shown that negative aspects (e.g., conflict) of marriage or marriage-like relationships are associated with poor health of offspring, but much less is known about the effects of positive aspects (e.g., affection) of parental romantic relationships. This study investigated links between conflict and affection within parents' romantic relationships and the health of youth with asthma. METHOD: Eighty youths with asthma aged 10-17 answered daily questions over a 4-day period about conflict and affection within their parents' romantic relationship, as well as their own daily mood, asthma symptoms, and expiratory peak flow. RESULTS: Multiple regression analyses revealed that romantic affection-but not conflict-was directly associated with higher expiratory peak flow. Further, there was a significant indirect effect of romantic affection via youth positive affect on lower asthma symptoms. CONCLUSION: These results are the first to our knowledge to demonstrate that youth-reported positive characteristics of parents' romantic relationships are associated with better health among youth with asthma. (PsycINFO Database Record

Neighborhood Stress, Depressive Symptoms, and Asthma Morbidity in Youth.

OBJECTIVE: Living in a dangerous and disadvantaged neighborhood is consistently linked with poor health outcomes; however, few studies have investigated psychosocial mechanisms of this relationship. We hypothesized that a specific facet of depression-anhedonia-would partially explain the relationship between stressful neighborhoods and poor health in youth with asthma. METHOD: 156 youths provided reports on their depressive symptoms, daily asthma symptoms, and peak expiratory flow rate (PEFR). Caregivers provided reports on neighborhood characteristics. RESULTS: Youth residing in more at-risk neighborhoods experienced more symptoms of depression, greater asthma symptoms (both during the day and night), and marginally lower PEFR. Indirect effect analyses revealed that the relationship between neighborhood stress and youth asthma symptoms was partially explained by a key symptom of depression, anhedonia. CONCLUSIONS: These findings suggest that the neighborhood-health link is partially explained by symptoms of depression tapping into difficulties experiencing pleasure and motivation.

Pursuing bariatric surgery in an urban area: Gender and racial disparities and risk for psychiatric symptoms.

BACKGROUND: Bariatric surgery is effective for weight loss; however, only a small percentage of those who qualify choose to pursue it. Additionally, although psychiatric symptoms appear to be common among candidates, the risk factors for symptoms are not known. Therefore, the purpose of this study was to examine the characteristics of those who are pursuing bariatric surgery in an urban area, whether demographic disparities continue to exist, and identify characteristics of those who may be at higher risk for experiencing psychiatric symptoms. METHODS: There were 424 bariatric candidates who completed a required psychological evaluation prior to bariatric surgery. RESULTS AND CONCLUSIONS: Bariatric surgery candidates tended to be middle-aged, Caucasian females, which was unexpected when compared to the rates of obesity among these groups. Therefore, it appears that there are disparities in who chooses to seek out bariatric surgery compared to those who may qualify due to their obesity status. Cultural factors may play a role in why males and African Americans seek out bariatric surgery less frequently. Psychiatric symptoms among candidates are also common, with depression symptoms increasing with age and BMI. Perhaps the compounding effects of medical comorbidities over time are contributing to greater depressive symptoms in the older patients. Findings from this study suggest that we may need to explore ways of encouraging younger patients, males, and ethnic minorities to pursue bariatric surgery to increase weight loss success and decrease medical comorbidities.

Asthma-Related Immune Responses in Youth With Asthma: Associations With Maternal Responsiveness and Expressions of Positive and Negative Affect in Daily Life.

OBJECTIVES: Stressful family environments early in life have negative effects on physical health. However, less is known about the health effects of positive aspects of families. We examined the associations between maternal responsiveness and immune markers among youth with asthma and identified youth expressions of positive affect as a potential mechanism of these associations. METHODS: Forty-three youths with asthma (26 boys; aged 10-17 years) wore the Electronically Activated Recorder for 4 days to assess maternal responsiveness and youth expressions of affect from audio-recordings of daily life. Trained coders rated Electronically Activated Recorder sound files for expressions of maternal responsiveness and affect displayed by the youth. Peripheral blood mononuclear cells were isolated, cultured, and assayed to determine stimulated levels of interleukin (IL)-5, IL-13, and interferon-γ. RESULTS: Greater maternal responsiveness was associated with decreased stimulated production of IL-5 (r = -0.38, p = .012) and IL-13 (r = -0.33, p = .031). Greater total positive affect in youth was linked to decreased stimulated production of IL-5 (r = -0.46, p = .002) and IL-13 (r = -0.37, p = .014). Total negative affect among youth was unrelated to immune responses. There was a significant indirect effect of maternal responsiveness via positive affect in youth on lower levels of IL-5 (95% confidence interval = -3.41 to -0.03) and IL-13 (95% confidence interval = -2.34 to -0.01) when adjusting for caregiver-youth conflict and negative affect among youth. CONCLUSIONS: These results indicate the importance of positive family interactions for youth and provide preliminary evidence for a mechanism through which parenting can influence immune responses in youth with asthma.

Naturalistically observed conflict and youth asthma symptoms.

OBJECTIVE: To investigate the links between naturalistically observed conflict, self-reported caregiver-youth conflict, and youth asthma symptoms. METHOD: Fifty-four youth with asthma (age range: 10-17 years) wore the Electronically Activated Recorder (EAR) for a 4-day period to assess interpersonal conflict and caregiver-youth conflict as they occur in daily life. Conflict also was assessed with baseline self-report questionnaires and daily diaries completed by youth participants and their caregivers. Asthma symptoms were assessed using daily diaries, baseline self-reports, and wheezing, as coded from the EAR. RESULTS: EAR-observed measures of conflict were strongly associated with self-reported asthma symptoms (both baseline and daily diaries) and wheezing coded from the EAR. Further, when entered together in regression analyses, youth daily reports of negative caregiver-youth interactions and EAR-observed conflict uniquely predicted asthma symptoms; only EAR-observed conflict was associated with EAR-observed wheezing. CONCLUSION: These findings demonstrate the potential impact of daily conflict on youth asthma symptoms and the importance of assessing conflict as it occurs in everyday life. More broadly, they point to the importance of formulating a clear picture of family interactions outside of the lab, which is essential for understanding how family relationships "get under the skin" to affect youth health.

Effects of socioeconomic status on maternal and child positive behaviors in daily life among youth with asthma.

OBJECTIVE: Socioeconomic disadvantage is associated with poorer behavioral and emotional outcomes in children with asthma. This study investigated the associations between maternal income and education and naturalistically observed behaviors and affect during everyday parent-child interactions. METHODS: 53 predominantly low-income youth with asthma, aged 10-17 years, wore a naturalistic event-sampling device, the Electronically Activated Recorder, for 4 days to assess mother and child positive behaviors and affect in daily life. RESULTS: Maternal education, but not income, was positively associated with child positive behaviors, displays of mother and child positive affect, and increased maternal responsiveness. Maternal positive affect and maternal responsiveness mediated the effect of maternal education on child positive affect. CONCLUSIONS: Our findings suggest that maternal education has an important influence on the socioemotional adjustment of youth with asthma and point to the importance of investigating the independent influence of socioeconomic status components on everyday parent-child interactions.