Crisis response among essential workers and their children during the COVID-19 pandemic.

Limited research has been conducted on the mental health concerns of frontline and essential workers and their children during the COVID-19 pandemic in the United States (U.S.). This study examined the association between working on the frontlines in the U.S. during the COVID-19 pandemic (March to July 2020) and personal crisis text concerns (e.g., self-harm, suicidal thoughts, anxiety/stress, and substance abuse) for frontline essential workers and the children of frontline workers. We used a novel data set from a crisis texting service, Crisis Text Line (CTL), that is widely used throughout the U.S. Generalized Estimating Equations examined the individual association between eight specific crisis types (Depression, Stress/Anxiety, Self-Harm, Suicidal Thoughts, Substance Abuse, Isolation, Relationship Issues, and Abuse) and being in frontline work or being a child of a frontline worker during the early phase of the pandemic. Using CTL concerns as a proxy for the prevalence of mental health issues, we found that children of workers, specifically the youngest demographic (13 years and under), females, and non-conforming youth had a higher risk of specific crisis events during the COVID-19 pandemic. Additionally, Hispanic children of workers reported higher rates of stress/anxiety, whereas African American children of workers had higher rates of abuse and depression. Frontline workers had a higher risk of suicidal thoughts, and the risk of crisis events was generally highest for non-binary, transgender, and male users. Increases in CTL usage among frontline workers were noted across 7-28 days after spikes in local COVID-19 cases. The research to date has focused on the mental health of frontline essential workers, but our study highlights troubling trends in psychological stress among children of these workers. Supportive interventions and mental health resources are needed not only for frontline essential workers, but for their children too.

Youth Mental Health in North Carolina: Creative Innovations in Challenging Times.

In this issue of the North Carolina Medical Journal, youth mental health is the focus. The second half of the title of this issue brief, "creative innovations in challenging times," was designed to convey a sense of optimism and urgency for the readers. The optimism centers on the joys of birth, the wonderments of childhood and adolescence, and the discoveries and connections between families and cultures among and within North Carolina communities. The sense of urgency pertains to the current epidemiologic realities for youth between the ages of 10 and 21 and the growing economic and health care disparities impacting the vast majority of North Carolinians. The author lineup for the issue is nothing short of exceptional and includes contributions from experts in epidemiology, suicide prevention, policy and law, school mental health, telemedicine, the impact of technology and social media on youth, innovations in the dissemination of psychological science to the public, attention-deficit hyperactivity disorders, diagnostic disparities, substance misuse and abuse, K-12 education, and systems of care for families. Serving as guest editor of this issue on youth mental health for the North Carolina Medical Journal has greatly expanded the breadth and depth of my understanding of the aforementioned issues relevant for today's youth. I hope that this issue is as informative to your work, regardless of your role in serving and advocating for young people in the great state of North Carolina.

Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis.

BACKGROUND: Major depressive disorder is one of the most common mental disorders in children and adolescents. However, whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. Consequently, we aimed to compare and rank antidepressants and placebo for major depressive disorder in young people. METHODS: We did a network meta-analysis to identify both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library, Web of Science, Embase, CINAHL, PsycINFO, LiLACS, regulatory agencies' websites, and international registers for published and unpublished, double-blind randomised controlled trials up to May 31, 2015, for the acute treatment of major depressive disorder in children and adolescents. We included trials of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. Trials recruiting participants with treatment-resistant depression, treatment duration of less than 4 weeks, or an overall sample size of less than ten patients were excluded. We extracted the relevant information from the published reports with a predefined data extraction sheet, and assessed the risk of bias with the Cochrane risk of bias tool. The primary outcomes were efficacy (change in depressive symptoms) and tolerability (discontinuations due to adverse events). We did pair-wise meta-analyses using the random-effects model and then did a random-effects network meta-analysis within a Bayesian framework. We assessed the quality of evidence contributing to each network estimate using the GRADE framework. This study is registered with PROSPERO, number CRD42015016023. FINDINGS: We deemed 34 trials eligible, including 5260 participants and 14 antidepressant treatments. The quality of evidence was rated as very low in most comparisons. For efficacy, only fluoxetine was statistically significantly more effective than placebo (standardised mean difference -0·51, 95% credible interval [CrI] -0·99 to -0·03). In terms of tolerability, fluoxetine was also better than duloxetine (odds ratio [OR] 0·31, 95% CrI 0·13 to 0·95) and imipramine (0·23, 0·04 to 0·78). Patients given imipramine, venlafaxine, and duloxetine had more discontinuations due to adverse events than did those given placebo (5·49, 1·96 to 20·86; 3·19, 1·01 to 18·70; and 2·80, 1·20 to 9·42, respectively). In terms of heterogeneity, the global I(2) values were 33·21% for efficacy and 0% for tolerability. INTERPRETATION: When considering the risk-benefit profile of antidepressants in the acute treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated. FUNDING: National Basic Research Program of China (973 Program).

The latent structure of social anxiety disorder and the performance only specifier: a taxometric analysis.

Social anxiety disorder (SAD) is often treated as a discrete diagnostic entity that represents a naturally occurring class, though empirical evidence largely supports a dimensional conceptualization of social fears. Further, the inclusion of a "performance only" specifier in the DSM-5 implies that individuals who experience intense social anxiety exclusively in performance situations are distinct from those with broader social fears. The purpose of the present research was to examine the latent structure of SAD and the DSM-5 "performance only" specifier in a large nonclinical sample (n = 2019). Three taxometric procedures (MAXCOV, MAMBAC, and L-Mode) were applied to indicators derived from two commonly used measures of social anxiety. Results yielded convergent evidence indicating that social anxiety exhibits a dimensional latent structure. Further, social performance anxiety demonstrates continuous relationships with milder social fears, suggesting that the "performance only" specifier may not represent a discrete entity. The implications of these findings for the assessment, diagnosis, classification, and treatment of social anxiety are discussed.

Systematic review of management for treatment-resistant depression in adolescents.

BACKGROUND: Current guidelines for treatment-resistant depression in adolescents remain inadequate. This study aimed to systematically review the management of treatment-resistant depression in adolescent patients. METHODS: We conducted an electronic database search of PUBMED, EMBASE, Cochrane, Web of Science and PsycINFO for studies with adolescent treatment-resistant depression published up to January 2014. Treatment-resistant depression was defined as failure to respond to at least one course of psychological or pharmacological treatment for depression with an adequate dosage, duration, and appropriate compliance during the current illness episode. The Cochrane risk-of-bias method was used to assess the quality of randomized controlled trials. A meta-analysis of all active treatments was conducted. RESULTS: Eight studies with 411 depressed adolescents that fit predetermined criteria investigated pharmacological treatments and psychotherapies. Six were open-label studies, and two were randomized controlled trials. The overall response rate for all active treatments investigated was 46% (95% CI 33 to 59; N = 411) with a moderately high degree of heterogeneity (I2 = 76.1%, 95% CI = 47%-86%). When only the two randomized trials were included, the overall response rate of active treatment was 53% (95% CI = 38-67; N = 347). In these randomized trials, SSRI therapy plus CBT was significantly more effective than SSRI therapy alone, while amitriptyline was not more effective than placebo. CONCLUSIONS: Approximately half of the adolescents who presented with treatment-refractory depression responded to active treatment, which suggests that practitioners should remain persistent in managing these challenging cases. The combination of antidepressant medication and psychotherapy should be recommended for adolescents who present with treatment-resistant depression.

CALM gatekeeper training is associated with increased confidence in utilizing means reduction approaches to suicide prevention among college resident assistants.

BACKGROUND: Most suicide prevention programs focus on increasing knowledge regarding the problem of suicide, yet many fail to include information on the science and application of means reduction approaches. In an attempt to address this gap in practice, the Counseling on Access to Lethal Means (CALM) program was developed to educate clinicians on the importance of means reduction interventions. METHODS: In the current study, a gatekeeper CALM training was delivered to 167 resident assistants. Confidence levels regarding suicide prevention and means reduction skills were assessed at baseline, post-training, and after a 6-week follow-up. RESULTS: Results were suggestive of medium to large training effects. Though there was a small decay of training effects at follow-up, the effects were durable when compared to baseline levels. CONCLUSION: Given these findings, future gatekeeper trainings should be provided more consistently to help sustain the effects and data on the implementation of CALM principles should be measured during follow-up assessments.

Understanding the concurrent risk of mental health and dangerous wildfire events in the COVID-19 pandemic.

Little research has examined the mental health risks of concurrent disasters. For example, disasters like wildfires have been shown to have a strong association with psychological symptoms-the 2020 U.S. Western wildfire season was the worst on record and occurred while the country was still navigating the COVID-19 pandemic. We implemented two quasi-experimental analyses, an interrupted time series analysis, and a difference-in-difference analysis to evaluate the impacts of wildfires and COVID-19 on mental health crisis help-seeking patterns. Both methods showed no statistical association between exposure to wildfires and the seeking of mental health support during the COVID-19 pandemic. Results highlighted that 2020 wildfires were not associated with an acute increase in crisis texts for youth in the two months after the events, likely due to an already elevated text volume in response to the COVID-19 pandemic from March 2020 throughout the fall wildfire season (Aug to Oct 2020). Future research is needed outside of the context of the pandemic to understand the effects of extreme and concurrent climatic events on adolescent mental health, and targeted interventions are required to ensure youth and adolescents are receiving adequate support during these types of crisis events.

Quasi-experimental evaluation of text-based crisis patterns in youth following Hurricane Florence in the Carolinas, 2018.

IMPORTANCE: Crisis text lines have proven to be an effective and low-cost means for delivering texting-based mental health support to youth. Yet there has been limited research examining the use of these services in capturing the psychological impact on youth affected by a weather-related disaster. OBJECTIVE: This ecologic study examined changes in help-seeking behavior for adolescents and young adults in North and South Carolina, USA, before and after Hurricane Florence (2018). DESIGN AND MAIN OUTCOMES: A retrospective, interrupted time-series design was used to examine pre- and post-hurricane changes in crisis text volume among youth help seekers in the Carolinas for the following outcomes: (1) text for any reason; (2) stress & anxiety; (3) depression; and (4) suicidal thoughts. RESULTS: Results showed an immediate and sustained increase in crisis texts for stress/anxiety and suicidal thoughts in the six weeks following Florence. Overall, an immediate 15% increase in crisis texts for anxiety/stress (SE = 0.05, p = .005) and a 17% increase in suicidal thoughts (SE = 0.07, p = .02) occurred during the week of the storm. Text volume for anxiety/stress increased 17% (SE = 0.08, p = .005) and 23% for suicidal ideation (SE = 0.08, p = .01) in the 6-week post-hurricane period. Finally, forecast models revealed observed text volume for all mental health outcomes was higher than expected in the 6 weeks post-Florence. CONCLUSIONS AND RELEVANCE: A low-cost, crisis texting platform provided 24/7 mental health support available to young people in the Carolinas impacted by Hurricane Florence. These findings highlight a new application for text-based crisis support services to address the mental health consequences in youth following a weather-related disaster, as well as the potential for these types of crisis platforms to measure situational awareness in impacted communities.

Crisis Text Line use following the release of Netflix series 13 Reasons Why Season 1: Time-series analysis of help-seeking behavior in youth.

The availability of near real-time data from Crisis Text Line (CTL) and other technology-based platforms on crisis events provides an opportunity for targeted interventions prior to serious mental health outcomes (e.g., suicide, self-harm). This study examined the association between the release of the popular Netflix series 13 Reasons Why (13RW) and CTL usage in a national sample of youth in the US. We implemented interrupted time-series, autoregressive integrated moving average (ARIMA) modeling to examine this association at a daily scale. We observed a significant but momentary rise in CTL conversation volume following the release of 13RW on April 5 and 6, 2017 followed by a significant reduction (12.7%) in conversation volume for the overall study period. This reduction in call volume was sustained for 49 days and is the most sustained reduction in conversation volume in the 365 day dataset. This unexpected trough in conversation volume is concerning in light of elevated search engine volume for terms indicating an increase in suicidal thoughts in the days following the release of the show (Ayers et al., 2017). CTL was featured by the show as a resource for viewers in the recently released Season 2, and our results highlight the reasoning and need for such promotion. Future work should explore whether the promotion of CTL in Season 2 positively impacted conversation volume, as there is a clear need to harness the power of these digital technologies to detect population-based trends in mental health and expand the reach of life saving services.

Crisis text patterns in youth following the release of 13 Reasons Why Season 2 and celebrity suicides: A case study of 2018.

There is considerable debate in the public arena and among the professional mental health community around the media's role in increasing suicide risk following exposure to suicide-themed media in youth. A recent example involves the concerning reaction to the release of Netflix's controversial hit teen-suicide drama 13 Reasons Why. This follow-up study examined the association between the release of 13 Reasons Why Season 2 (13RW2), which coincided with two celebrity suicides, and national trends in crisis-related text conversations. We implemented an interrupted time series design to examine changes in daily counts of crisis texts aggregated at the national level following two events: (1) the release of 13RW2 and (2) celebrity suicide deaths of Anthony Bourdain and Kate Spade. We also performed a sub-analysis of suicide-related crisis conversations following each event. Crisis conversation volume was 42% higher after the release of 13RW2 for 6 of the 18 days of the study period, while crisis text usage was 51% higher for 9 out of the 18 days after the publicized celebrity suicide deaths. Both the release of 13RW2 and the celebrity suicides in the summer of 2018 were followed by an abrupt, but transient rise in crisis help-seeking among adolescents. Media outlets should consider pairing suicide-themed content with crisis support services as a core best practice to reduce the risk of population-level adverse reactions to suicide portrayals or coverage.

Nonsuicidal Self-Injury and Suicidal Self-Injury: A Taxometric Investigation.

The present research examined the latent structure of self-injurious behavior (SIB) to determine whether suicidal self-injury (SSI) and nonsuicidal self-injury (NSSI) reflect categorically distinct types of SIB or dimensional variations of the same construct. Participants consisted of 1,525 female undergraduates across several universities in the United States who completed the Survey of College Mental Health and Well Being and endorsed a history of SIB. Empirically derived indicators representing intent to die, suicidal history, frequency of SIB, severity of SIB, and number of methods of SIB were submitted to three mathematically independent taxometric procedures. Results of multiple consistency tests converged to indicate that the latent structure of SIB is continuous, with individuals who engage in SSI and NSSI differing in degree rather than kind. The implications of these dimensional findings for the theoretical conceptualization, assessment, and treatment of SIB are discussed.

Comparative efficacy and tolerability of first-generation and newer-generation antidepressant medications for depressive disorders in children and adolescents: study protocol for a systematic review and network meta-analysis.

INTRODUCTION: Depressive disorders are among the most common psychiatric disorders in children and adolescents, and have adverse effects on their psychosocial functioning. Questions concerning the efficacy and safety of antidepressant medications in the treatment of depression in children and adolescents, led us to integrate the direct and indirect evidence using network meta-analysis to create hierarchies of these drugs. METHODS AND ANALYSIS: Seven databases with PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL, LiLACS and PsycINFO will be searched from 1966 to December 2013 (updated to May, 2015). There are no restrictions on language or type of publication. Randomised clinical trials assessing first-generation and newer-generation antidepressant medications against active comparator or placebo as acute treatment for depressive disorders in children and adolescents (under 18 years of age) will be included. The primary outcome for efficacy will be mean improvement in depressive symptoms, as measured by the mean change score of a depression rating scale from baseline to post-treatment. The tolerability of treatment will be defined as side effect discontinuation, as defined by the proportion of patients who discontinued treatment due to adverse events during the trial. We will also assess the secondary outcome for efficacy (response rate), acceptability (all-cause discontinuation) and suicide-related outcomes. We will perform the Bayesian network meta-analyses for all relative outcome measures. Subgroup analyses and sensitivity analyses will be conducted to assess the robustness of the findings. DISSEMINATION: The network meta-analysis will provide useful information on antidepressant treatment for child and adolescent depression. The results will be disseminated through peer-reviewed publication or conference presentations. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015016023.

Psychotherapy for depression in children and adolescents: study protocol for a systematic review and network meta-analysis.

INTRODUCTION: Depression is common among children and adolescents and is associated with significantly negative effects. A number of structured psychosocial treatments are administered for depression in children and adolescents; however, evidence of their effectiveness is not clear. We describe the protocol of a systematic review and network meta-analysis to evaluate the efficacy, quality of life, tolerability and acceptability of the use of psychological intervention for this young population. METHODS AND ANALYSIS: We will search PubMed, EMBASE, CENTRAL (the Cochrane Central Register of Controlled Trials), Web of Science, PsycINFO, CINAHL, LiLACS, Dissertation Abstracts, European Association for Grey Literature Exploitation (EAGLE) and the National Technical Information Service (NTIS) from inception to July 2014. There will be no restrictions on language, publication year or publication type. Only randomised clinical trials (RCTs) with psychosocial treatments for depression in children and adolescents will be considered. The primary outcome of efficacy will be the mean overall change of the total score in continuous depression severity scales from baseline to end point. Data will be independently extracted by two reviewers. Traditional pairwise meta-analyses will be performed for studies that directly compared different treatment arms. Then we will perform a Bayesian network meta-analyses to compare the relative efficacy, quality of life, tolerability and acceptability of different psychological intervention. Subgroup analyses will be performed by the age of participants and the duration of psychotherapy, and sensitivity analyses will be conducted to assess the robustness of the findings. ETHICS AND DISSEMINATION: No ethical issues are foreseen. The results will be published in a peer-reviewed journal and disseminated electronically and in print. The meta-analysis may be updated to inform and guide management of depression in children and adolescents. TRIALS REGISTRATION NUMBER: PROSPERO CRD42014010014.

Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis.

Previous meta-analyses of psychotherapies for child and adolescent depression were limited because of the small number of trials with direct comparisons between two treatments. A network meta-analysis, a novel approach that integrates direct and indirect evidence from randomized controlled studies, was undertaken to investigate the comparative efficacy and acceptability of psychotherapies for depression in children and adolescents. Systematic searches resulted in 52 studies (total N=3805) of nine psychotherapies and four control conditions. We assessed the efficacy at post-treatment and at follow-up, as well as the acceptability (all-cause discontinuation) of psychotherapies and control conditions. At post-treatment, only interpersonal therapy (IPT) and cognitive-behavioral therapy (CBT) were significantly more effective than most control conditions (standardized mean differences, SMDs ranged from -0.47 to -0.96). Also, IPT and CBT were more beneficial than play therapy. Only psychodynamic therapy and play therapy were not significantly superior to waitlist. At follow-up, IPT and CBT were significantly more effective than most control conditions (SMDs ranged from -0.26 to -1.05), although only IPT retained this superiority at both short-term and long-term follow-up. In addition, IPT and CBT were more beneficial than problem-solving therapy. Waitlist was significantly inferior to other control conditions. With regard to acceptability, IPT and problem-solving therapy had significantly fewer all-cause discontinuations than cognitive therapy and CBT (ORs ranged from 0.06 to 0.33). These data suggest that IPT and CBT should be considered as the best available psychotherapies for depression in children and adolescents. However, several alternative psychotherapies are understudied in this age group. Waitlist may inflate the effect of psychotherapies, so that psychological placebo or treatment-as-usual may be preferable as a control condition in psychotherapy trials.

How effective are treatments for child and adolescent depression? A meta-analytic review.

We located a comprehensive sample of studies (1980-1999) on the psychosocial and pharmacological treatment of child and adolescent depression through an extensive literature search. Articles that met the inclusionary criteria were subsequently analyzed. The outcome data from 38 studies were extracted and converted into effect sizes (ESs). Comparisons of main effects, demographic, and quality of study variables were conducted. The overall findings of this meta-analysis indicate that several different psychosocial interventions for child and adolescent depression produced moderate to large treatment gains that were clinically meaningful for many afflicted youth. However, in general, the vast majority of pharmacological interventions were not effective in treating depressed children and adolescents. Nonetheless, there is recent evidence that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are efficacious, and will likely play an increased role in the management of affective illness in youngsters. The clinical implications and limitations of these data are discussed and suggestions for future research are provided.

Gender differences in the association among nicotine dependence, body image, depression, and anxiety within a college population.

Previous research has linked female weight concerns and smoking. This study examined whether poor body image and other eating disorder variables, after controlling for symptoms of anxiety and depression, were predictive of smoking severity in a sample of 478 college students (n=215 males, n=246 females). Contrary to our hypotheses and recent research, the predictors were not associated with nicotine dependence for females (R(2)=.00), and only dieting was negatively associated with nicotine dependence for males. These findings might be attributable to differences in how nicotine dependence is operationalized, the use of point prevalence symptom data versus lifetime prevalence of psychopathology, the severity of psychopathology in the present sample, or the use of a cross-sectional as opposed to a longitudinal design.

Young adult romantic couples' conflict resolution and satisfaction varies with partner's attention-deficit/hyperactivity disorder type.

Attention-deficit/hyperactivity disorder (ADHD) has previously been associated with less satisfaction and success in romantic relationships. This study compares conflict resolution and problem-solving behaviors in young adult romantic couples either having one partner with ADHD combined type (C-couples), having one partner identified with ADHD inattentive type (IA-couples), or in which neither partner has an ADHD diagnosis (nondiagnosed [ND] couples). Self-reports of current and childhood ADHD symptoms corroborated diagnostic status and speaker and listener behaviors, coded via the Rapid Couples Interaction Scoring System (Gottman, 1996), were the primary dependent variables. Analyses revealed greater negativity and less positivity in C-couples' behavior during a conflict resolution task, relative to IA and ND couples, and this corresponded with couples' relational satisfaction. IA-couples emitted relational behavior that was largely similar to ND couples. Findings support that relational impairment exists in C-couples, and to some degree, contrast with previous research suggesting that individuals with predominant inattention experience greater social impairment in adulthood than those with other types of ADHD.

The effects of physiological arousal on cognitive and psychomotor performance among individuals with high and low anxiety sensitivity.

Information-processing models of anxiety posit that anxiety pathology is associated with processing biases that consume cognitive resources and may detract from one's ability to process environmental stimuli. Previous research has consistently indicated that high anxiety has a negative impact on cognitive and psychomotor performance. Anxiety sensitivity, or the fear of anxiety and anxiety-related arousal sensations, is an anxiety vulnerability factor that has been shown to play a role in the development and maintenance of panic attacks and panic disorder. However, relatively little is known regarding the potential impact of anxiety sensitivity on performance. In the present study, 105 college students who scored either high (≥ 24) or low (≤ 14) on the Anxiety Sensitivity Index were randomly assigned to complete a series of arousal-induction tasks or no activity, followed immediately by three cognitive and psychomotor performance tasks: digit span - backward, math fluency, and grooved pegboard. Results indicated that participants with high anxiety sensitivity performed comparably to individuals with low anxiety sensitivity on each task, regardless of arousal level.