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My long day’s journey into sleep began as an adolescent trying to manage my evening chronotype. The relief I felt when my undergraduate finals were scheduled at night and as a medical student being able to select psychiatry over surgery deepened my interest in sleep and chronobiology. That interest was allowed to flourish at the National Institute of Mental Health and then at Yale Medical School in setting up a sleep laboratory. The decision to move to the University of Pittsburgh in 1973 led to a 42-year adventure in which we were able to initiate research efforts on the psychobiology of depression. Our interest in social zeitgebers (daily routines) led directly to the development and testing of a treatment intervention for mood disorders, interpersonal and social rhythm therapy. Our continued emphasis on sleep and circadian rhythms convinced us that sleep and circadian factors were central to all of health, based on the importance of connectivity between sleep and major metabolic and cell functions. This ongoing research motivated to our strong desire to study developmental aspects of sleep. Our success was influenced immensely by the presence of young scientists and a strong subsequent interest in career mentoring. Finally, as we left Pittsburgh in 2015, we became involved in the field of continuous objective monitoring using the commercial smartphone’s behavioral sensing capabilities. Our journey is not over. We hope to explore the potential of these remarkable devices to improve our understanding of sleep/wake and circadian factors across all of health.

Financial counseling has been found to be effective in improving consumers' credit outcomes and could be expanded through the workplace to reach lower-income workers who struggle with various financial challenges. We examine engagement and credit outcomes associated with a workplace financial counseling program offered to 2,849 frontline workers in New York City. Age and credit scores helped explain variation in types of engagement in services. Credit outcomes were modest on average, but greater among workers who received three or more counseling sessions, had low and no baseline credit scores, and reduced the number of delinquent and collections accounts on their credit reports. Workplace financial counseling is a promising strategy to proactively promote credit outcomes among frontline workers, though counselors should be flexible in offering services and help workers access affordable credit products available to those with subprime credit scores and increase financial slack to lessen dependence on credit.

Objective At least half of youths with mental disorders are unrecognized and untreated. Rapid, accurate assessment of child mental disorders could facilitate identification and referral and potentially reduce the occurrence of functional disability that stems from early-onset mental disorders. Method Computerized adaptive tests (CATs) based on multidimensional item response theory were developed for depression, anxiety, mania/hypomania, attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, and suicidality, based on parent and child ratings of 1,060 items each. In phase 1, CATs were developed from 801 participants. In phase 2, predictive, discriminant, and convergent validity were tested against semi-structured research interviews for diagnoses and suicidality in 497 patients and 104 healthy controls. Overall strength of association was determined by area under the receiver operating characteristic curve (AUC). Results The child and parent independently completed the Kiddie−Computerized Adaptive Tests (K-CATs) in a median time of 7.56 and 5.03 minutes, respectively, with an average of 7 items per domain. The K-CATs accurately captured the presence of diagnoses (AUCs from 0.83 for generalized anxiety disorder to 0.92 for major depressive disorder) and suicidal ideation (AUC = 0.996). Strong correlations with extant measures were found (r ≥ 0.60). Test−retest reliability averaged r = 0.80. Conclusion These K-CATs provide a new approach to child psychopathology screening and measurement. Testing can be completed by child and parent in less than 8 minutes and yields results that are highly convergent with much more time-consuming structured clinical interviews and dimensional severity assessment and measurement. Testing of the implementation of the K-CAT is now indicated.

Interest among employers is growing in employee financial wellness programs (EFWPs), a new type of benefit to address financial stress among employees. EFWP benefits include financial counseling, small-dollar loans, and savings programs that address employees’ nonretirement financial needs. Little evidence exists concerning the availability and use of and outcomes associated with EFWPs, especially among low- and moderate-income (LMI) workers who may be in the greatest need of these benefits. We present findings concerning awareness and use of EFWPs from a national survey of LMI workers ( N = 16,650). Availability of different EFWP benefits ranged from 11 to 15% and over a third of workers were unaware of whether their employer offered an EFWP. Experiencing financial difficulties predicted both EFWP awareness and use suggesting that employers should take time to assess employees’ specific financial challenges to select benefits. Yet, use of EFWPs by LMI workers may suggest the need for better compensation and work conditions.

Employee financial wellness programs (EFWPs) are a new practice that may promote financial inclusion by making it easier for workers with low- and moderate-incomes (LMI) to access financial service...

Background Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 min) calls from clinical helpers (CH). Methods Participants (n = 47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks. Results RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1 ± 5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d = 0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d = 1.3]. ARM also showed moderate effects (ISS-ACT d = 0.7; Quick Inventory of Depressive Symptoms, d = 0.8). SF-12 MHC scores showed a time*group interaction (F = 2.38, df = 6,32, p = 0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F = 4.09, df = 1, 17, p = 0.06). Limitations Sample size is small, limiting conclusions that can be drawn. Conclusions Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.

Employee financial wellness programs (EFWPs) are a benefit innovation that promise to address the financial challenges of employees while also benefiting employers. Results from a mixed-methods stu...

We thank Kaufman et al.1 for their comprehensive review of the many commendable features of the Kiddie-Computerized Adaptive Test (K-CAT). We do wish to clarify what may be a misunderstanding of the intent of the K-CAT and our view of its role in treatment planning.

Objective: Up to 60% of patients with bipolar disorder develop a substance use disorder during their lifetime. The purpose of this paper was to assess the impact of substance use disorders on depression recovery among bipolar patients randomly assigned to different psychotropic medications and psychosocial interventions. We hypothesized that patients with a comorbid substance use disorder would benefit less from psychotherapy regardless of treatment intensity/length compared to patients without a comorbid substance use disorder. Method: We conducted post hoc analyses among bipolar disorder patients ( n = 270) with and without comorbid substance use disorders enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder randomized psychosocial intervention trial. All patients entered during or shortly after the onset of a bipolar depressive episode. Logistic regression and Cox proportional hazard models were used to assess whether current or past substance use disorders moderated the response of patients to intensive psychosocial intervention or brief psychoeducation with collaborative care, operationalized as full recovery from an episode of bipolar depression. Results: Current comorbid substance use disorders significantly predicted likelihood of recovery (odds ratio = 2.25, p = 0.025) and time to recovery (odds ratio = 1.71, p = 0.006) from bipolar depression. We found that 74.5% of patients with a current substance use disorder, compared to 56.5% without a current substance use disorder, recovered from bipolar depression. Past substance use disorders did not predict likelihood of recovery or time to recovery. Current substance use disorders did not significantly moderate response to intensive psychotherapy versus collaborative care. Conclusion: Contrary to our hypotheses, bipolar disorder participants with a current comorbid substance use disorder were more likely to recover from psychosocial treatment for bipolar depression than patients without a current comorbid substance use disorder. If this finding is replicated, it has implications for the ordering of treatment for patients with comorbid bipolar disorder and substance use disorders.

Purpose of review Depression is a complex and burdensome condition; it often leads to personal, societal and economic costs. Despite advances in treatments, its management over time remains a challenge; many treated for depression do not achieve full recovery or remain well for long. Novel ways to monitor patients are warranted, as well as better understanding of contributors to relapse or sustained wellness. Mobile health technologies (m-Health) are emerging as useful tools for real-time assessments of moods, behaviours and activities in a more convenient and less burdensome manner. Yet, there are numerous questions around privacy, reliability and accuracy of data collected via mobile apps. This review provides a critical overview of advances in m-Health and evaluate the future potential of smartphone technology in the assessment and treatment of depression. Recent findings There is an abundance of apps in the market that claim to exert beneficial effects on the management of depression; to date, only a small fraction has been validated in clinical trials or has had the support of academic centers. Summary Although promising, the use of mobile health applications in depression warrants further investigation and incorporation into mainstream research to facilitate greater adoption and validation of its clinical utility.

I found this book to be a good historical representation and accurate account of the foods that encompass Southwestern cuisine, dating back from some of the first early migrations of the past, whic...

Key Points Question Can rapid psychometrically sound adaptive diagnostic screening and dimensional severity measures be developed for posttraumatic stress disorder? Findings In this diagnostic study including 713 US military veterans, the Computerized Adaptive Diagnostic–Posttraumatic Stress Disorder measure was shown to have excellent diagnostic accuracy. The Computerized Adaptive Test–Posttraumatic Stress Disorder also provided valid severity ratings and demonstrated convergent validity with the Post-Traumatic Stress Disorder checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Meaning In this study, the Computerized Adaptive Diagnostic–Posttraumatic Stress Disorder and Computerized Adaptive Test–Posttraumatic Stress Disorder measures appeared to provide valid screening diagnoses and severity scores, with substantial reductions in patient and clinician burden., Importance Veterans from recent and past conflicts have high rates of posttraumatic stress disorder (PTSD). Adaptive testing strategies can increase accuracy of diagnostic screening and symptom severity measurement while decreasing patient and clinician burden. Objective To develop and validate a computerized adaptive diagnostic (CAD) screener and computerized adaptive test (CAT) for PTSD symptom severity. Design, Setting, and Participants A diagnostic study of measure development and validation was conducted at a Veterans Health Administration facility. A total of 713 US military veterans were included. The study was conducted from April 25, 2017, to November 10, 2019. Main Outcomes and Measures The participants completed a PTSD-symptom questionnaire from the item bank and provided responses on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5). A subsample of 304 participants were interviewed using the Clinician-Administered Scale for PTSD for DSM-5. Results Of the 713 participants, 585 were men; mean (SD) age was 52.8 (15.0) years. The CAD-PTSD reproduced the Clinician-Administered Scale for PTSD for DSM-5 PTSD diagnosis with high sensitivity and specificity as evidenced by an area under the curve of 0.91 (95% CI, 0.87-0.95). The CAT-PTSD demonstrated convergent validity with the PCL-5 (r = 0.88) and also tracked PTSD diagnosis (area under the curve = 0.85; 95% CI, 0.79-0.89). The CAT-PTSD reproduced the final 203-item bank score with a correlation of r = 0.95 with a mean of only 10 adaptively administered items, a 95% reduction in patient burden. Conclusions and Relevance Using a maximum of only 6 items, the CAD-PTSD developed in this study was shown to have excellent diagnostic screening accuracy. Similarly, using a mean of 10 items, the CAT-PTSD provided valid severity ratings with excellent convergent validity with an extant scale containing twice the number of items. The 10-item CAT-PTSD also outperformed the 20-item PCL-5 in terms of diagnostic accuracy. The results suggest that scalable, valid, and rapid PTSD diagnostic screening and severity measurement are possible., This diagnostic study develops and validates a tool for use in diagnostic screening of US military veterans for posttraumatic stress disorder.

There are substantial gaps in understanding near-term precursors of suicidal ideation in bipolar II disorder. We evaluated whether repeated patient-reported mood and energy ratings predicted subsequent near-term increases in suicide ideation.Secondary data were used from 86 depressed adults with bipolar II disorder enrolled in one of 3 clinical trials evaluating Interpersonal and Social Rhythm Therapy and/or pharmacotherapy as treatments for depression. Twenty weeks of daily mood and energy ratings and weekly Hamilton Depression Rating Scale (HDRS) were obtained. Penalized regression was used to model trajectories of daily mood and energy ratings in the 3 week window prior to HDRS Suicide Item ratings.Participants completed an average of 68.6 (sd=52) days of mood and energy ratings. Aggregated across the sample, 22% of the 1675 HDRS Suicide Item ratings were non-zero, indicating presence of at least some suicidal thoughts. A cross-validated model with longitudinal ratings of energy and depressed mood within the three weeks prior to HDRS ratings resulted in an AUC of 0.91 for HDRS Suicide item2, accounting for twice the variation when compared to baseline HDRS ratings. Energy, both at low and high levels, was an earlier predictor than mood.Data derived from a heterogeneous treated sample may not generalize to naturalistic samples. Identified suicidal behavior was absent from the sample so it could not be predicted.Prediction models coupled with intensively gathered longitudinal data may shed light on the dynamic course of near-term risk factors for suicidal ideation in bipolar II disorder.

Aims To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD)-bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT), and cognitive behavioral therapy adapted for BD (CBTI-BP)-and propose treatment recommendations based on a synthesis of the evidence. Methods PRISMA-based systematic review of the literature. Results The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, three randomized controlled trials (RCTs), and one pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3%, and 59.4% in eight case series, 11 uncontrolled, studies, and one RCT, respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The seven studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67%, and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in two RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated. Conclusions The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.

A symposium held at the 31st European College of Neuropsychopharmacology congress in October 2018 in Barcelona, Spain discussed patients' expectations of treatment of their depression and how these can be integrated into patient management. Since treatment non-compliance is a major problem in patients suffering from depression, it is important to identify patients' expectations to improve treatment compliance and in turn efficacy. Currently, there is no established protocol for choosing the right antidepressant therapy, and physicians need to tailor the choice based on the type of depression, its predominant symptoms, medical and psychiatric history of patients, and their previous response to, and adverse events with, treatment. Treatment strategies also need to be adapted to each patient's personality/persona and their personal beliefs, and patients need to be aware of the potential for drug-associated adverse events such as emotional blunting, sexual dysfunction and loss of functional outcomes, as the expectation of these events may limit their impact on treatment discontinuation. Also, placebo effects remain frequent with treatment, and there is currently no agreed method for predicting response to therapy. Of the available methods to determine treatment response, pharmacogenetic testing has limited value while functional imaging may be valuable, but is not practical in routine clinical practice. Online cognitive behavioural therapy (CBT) represents a new option in the clinical management of patients with depression, particularly for patients who may not be able to access direct interaction with a psychotherapist because of the severity of their condition, their geographic location or socioeconomic situation. Online CBT can act as an adjunct to drug treatment and face-to-face psychotherapy, rather than as the sole form of treatment to aid in identifying a patient's needs, thus meeting the treatment gap and improving compliance and efficacy.Funding: Servier. ispartof: ADVANCES IN THERAPY vol:36 issue:SUPPL 3 pages:S73-S90 ispartof: location:United States status: published

We aim to close a methodological gap in analyzing durations of successive events that are subject to induced dependent censoring as well as competing-risk censoring. In the Bipolar Disorder Center for Pennsylvanians study, some patients who managed to recover from their symptomatic entry later developed a new depressive or manic episode. It is of great clinical interest to quantify the association between time to recovery and time to recurrence in patients with bipolar disorder. The estimation of the bivariate distribution of the gap times with independent censoring has been well studied. However, the existing methods cannot be applied to failure times that are censored by competing causes such as in the Bipolar Disorder Center for Pennsylvanians study. Bivariate cumulative incidence function has been used to describe the joint distribution of parallel event times that involve multiple causes. To the best of our knowledge, however, there is no method available for successive events with competing-risk censoring. Therefore, we extend the bivariate cumulative incidence function to successive events data, and propose non-parametric estimators of the bivariate cumulative incidence function and the related conditional cumulative incidence function. Moreover, an odds ratio measure is proposed to describe the cause-specific dependence, leading to the development of a formal test for independence of successive events. Simulation studies demonstrate that the estimators and tests perform well for realistic sample sizes, and our methods can be readily applied to the Bipolar Disorder Center for Pennsylvanians study.

This paper focuses on the relationship between the circadian system and glucose metabolism. Research across the translational spectrum confirms the importance of the circadian system for glucose metabolism and offers promising clues as to when and why these systems go awry. In particular, basic research has started to clarify the molecular and genetic mechanisms through which the circadian system regulates metabolism. The study of human behavior, especially in the context of psychiatric disorders, such as bipolar disorder and major depression, forces us to see how inextricably linked mental health and metabolic health are. We also emphasize the remarkable opportunities for advancing circadian science through big data and advanced analytics. Advances in circadian research have translated into environmental and pharmacological interventions with tremendous therapeutic potential.

In this Seminar we discuss developments from the past 5 years in the diagnosis, neurobiology, and treatment of major depressive disorder. For diagnosis, psychiatric and medical comorbidity have been emphasised as important factors in improving the appropriate assessment and management of depression. Advances in neurobiology have also increased, and we aim to indicate genetic, molecular, and neuroimaging studies that are relevant for assessment and treatment selection of this disorder. Further studies of depression-specific psychotherapies, the continued application of antidepressants, the development of new treatment compounds, and the status of new somatic treatments are also discussed. We address two treatment-related issues: suicide risk with selective serotonin reuptake inhibitors, and the safety of antidepressants in pregnancy. Although clear advances have been made, no fully satisfactory treatments for major depression are available.(Reprinted with permission from the Lancet 2012; 379: 1045–55)

Objective To understand self-monitoring strategies used independently of clinical treatment by individuals with bipolar disorder (BD), in order to recommend technology design principles to support mental health management.Materials and Methods Participants with BD (N = 552) were recruited through the Depression and Bipolar Support Alliance, the International Bipolar Foundation, and WeSearchTogether.org to complete a survey of closed- and open-ended questions. In this study, we focus on descriptive results and qualitative analyses.Results Individuals reported primarily self-monitoring items related to their bipolar disorder (mood, sleep, finances, exercise, and social interactions), with an increasing trend towards the use of digital tracking methods observed. Most participants reported having positive experiences with technology-based tracking because it enables self-reflection and agency regarding health management and also enhances lines of communication with treatment teams. Reported challenges stem from poor usability or difficulty interpreting self-tracked data.Discussion Two major implications for technology-based self-monitoring emerged from our results. First, technologies can be designed to be more condition-oriented, intuitive, and proactive. Second, more automated forms of digital symptom tracking and intervention are desired, and our results suggest the feasibility of detecting and predicting emotional states from patterns of technology usage. However, we also uncovered tension points, namely that technology designed to support mental health can also be a disruptor.Conclusion This study provides increased understanding of self-monitoring practices, attitudes, and needs of individuals with bipolar disorder. This knowledge bears implications for clinical researchers and practitioners seeking insight into how individuals independently self-manage their condition as well as for researchers designing monitoring technologies to support mental health management.

Objective Bipolar II disorder (BP-II) is associated with marked morbidity and mortality. Quetiapine, the treatment with greatest evidence for efficacy in BP-II depression, is associated with metabolic burden. Psychotherapy, a treatment with few side effects, has not been systematically evaluated in BP-II. This study compared psychotherapy plus placebo to psychotherapy plus pharmacotherapy as treatments for BP-II depression. Methods From 2010 to 2015, unmedicated adults (n = 92) with DSM-IV-TR BP-II depression were randomly assigned to weekly sessions of Interpersonal and Social Rhythm Therapy (IPSRT) plus placebo or IPSRT plus quetiapine and followed for 20 weeks. Results For primary outcomes, IPSRT + quetiapine yielded significantly faster improvement on 17-item Hamilton Depression Rating Scale (F₁,₁₁₅.₄ = 3.924, P = .048) and greater improvement on Young Mania Rating Scale (F₅₈.₅ = 4.242, P = .044) scores. Both groups, however, improved significantly over time with comparable response rates (≥ 50% reduction in depression scores): 67.4% (62/92) in the entire sample, with no between-group differences. Those randomly assigned to their preferred treatment were 4.5 times more likely to respond (OR = 4.48, 95% CI = 1.20-16.77, P = .026). IPSRT + quetiapine assignment was associated with significantly higher body mass index over time (F₆₇.₉₆ = 6.671, P = .012) and rates of dry mouth (79% v. 58%; χ² = 4.0, P = .046) and a trend toward more complaints of oversedation (100% vs 92%; χ² = 3.4, P = .063). Conclusions IPSRT plus quetiapine resulted in greater symptomatic improvement but also more side effects than IPSRT alone. A subset of participants improved with IPSRT alone, although absence of an inactive comparator limits interpretation of this finding. Receipt of preferred treatment was associated with better outcomes. Harms, benefits, and preferences should be considered when recommending treatments for BP-II depression. Trial registration ClinicalTrials.gov identifier: NCT01133821.

Childhood trauma has been related to adverse behavioral, mental, and health outcomes later in life. Sleep may be a potential mechanism through which childhood trauma is related to adverse health. The current retrospective study aimed to characterize the relationship between childhood trauma exposure and sleep health, a novel multidimensional measure of sleep.Participants (N = 161; mean [standard deviation] age = 59.85 [9.06] years; 67.7% female) retrospectively reported trauma exposure using the Trauma History Questionnaire. Childhood trauma was defined as the number of reported traumatic events before 18 years of age. Trauma exposure after 18 years of age and across the life-span was also recorded. Sleep health was derived both from diary- and actigraphy-assessed measures of sleep regularity, timing, efficiency, and duration, subjective sleep satisfaction, and daytime sleepiness from the Epworth Sleepiness Scale. The relationships between childhood trauma exposure and sleep health were examined using hierarchical linear regression, controlling for relevant covariates.In unadjusted models, a greater number of childhood trauma exposures were associated with poorer diary- and actigraphy-measured sleep health in adulthood. After adjustment for current stress, depression history, and other sociodemographic covariates, greater childhood trauma remained significantly associated with poorer sleep health (diary: β = -0.20, ΔR = 0.032; actigraphy: β = -0.19, ΔR = 0.027). Trauma exposure after 18 years of age and across the life-span did not relate to diary- or actigraphy-based sleep health.Childhood trauma may affect sleep health in adulthood. These findings align with the growing body of evidence linking childhood trauma to adverse health outcomes later in life.

Objective To conduct a pilot randomized trial of Interpersonal and Social Rhythm Therapy plus Data-Informed Referral (IPSRT + DIR) versus DIR-alone for adolescents at-risk for bipolar disorder (BP). Method Eligible participants included youth (12–18) with a BP parent; youth with BP were excluded. Participants (n = 42) were randomized to receive IPSRT + DIR to treat any psychiatric disorders present at baseline, or DIR-alone. A blind evaluator assessed outcomes at baseline, 3- and 6-months. Participants wore an actigraph to measure sleep/wake patterns for 7 days at baseline and 6-months. Primary outcomes included mood and non-mood symptoms and sleep disturbance. Results Youth randomized to IPSRT + DIR attended approximately half of scheduled IPSRT sessions. Although 33% of DIR-alone youth were referred for mental health services at intake (another 33% were already engaged in services), none initiated new services over follow-up. No youth developed new-onset mood disorder over follow-up. Self- and parent-reported mood and non-mood psychiatric symptoms did not distinguish the groups, although youth in DIR-alone tended to have higher baseline scores on most measures. Per clinician ratings, 1 youth receiving IPSRT + DIR displayed subthreshold hypo/manic symptoms, versus 2 receiving DIR-alone (OR = 14.7, p = 0.03), possibly signaling less subthreshold hypo/manic symptoms, and for fewer weeks (χ2= 11.06, p = 0.0009), over 6-months with IPSRT + DIR. We found a small effect for youth in the IPSRT + DIR group to evidence more WASO at pre-treatment, but less at follow-up (cohen's d = 0.28). Limitations Small sample size limits statistical power, and we are unable to definitively attribute group differences to IPSRT versus greater clinical contact. Ability to examine distal/rare (i.e., BP onset) outcomes was limited. Conclusions Adolescents at-risk for BP present challenges to psychosocial treatment engagement and retention. IPSRT merits further study as an acceptable intervention for at-risk youth, though necessary frequency and intensity to affect outcomes should be examined. The potential to delay or prevent subthreshold hypo/manic symptoms via enhanced sleep continuity is an area for further examination. Future studies with larger samples and extended follow-up can help determine whether IPSRT may delay or prevent syndromal hypo/mania in youth at-risk.

Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder.The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT.Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials.Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.

Objective:The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health system.Methods:Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques.Results:Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques.Conclusions:Internet-supported e-learning by community clinicians was found to be feas...

Research on health service utilization among the elderly is unambiguous in finding that those who are the most heavily insured use the most health services. What is less clear, however, is whether the favorable effect of health insurance coverage holds for low-income populations. As such, this study uses data from the Rand version of the Health Retirement Study spanning the years 2002 to 2010 to examine the extent of heterogeneous use of health services within the population of elderly poor and the degree to which health insurance status moderates the effect of poverty on health service utilization.

Older women seeking employment often find opportunities limited to low-wage jobs, such as those in retail. We report findings about job placement and starting wages for hourly workers hired at a women's apparel retailer from August 2006 to December 2009. We examine competing hypotheses regarding the role of age in explaining women's job placement and starting wages. Although newly hired women age 55+ earn higher wages and are placed in higher-quality jobs than the youngest women (ages 18-22), they are less likely to be placed in better-quality jobs than their midlife counterparts. Overall, wage differences are largely explained by job quality.

We conducted a randomized, controlled trial comparing the efficacy of an Integrated Risk Reduction Intervention (IRRI) to a control condition with the objective of improving mood stability and psychosocial functioning by reducing cardiometabolic risk factors in overweight/obese patients with bipolar I disorder.A total of 122 patients were recruited from our outpatient services and randomly allocated to IRRI (n = 61) or psychiatric care with medical monitoring (n = 61). Individuals allocated to IRRI received psychiatric treatment and assessment, medical monitoring by a nurse, and a healthy lifestyle program from a lifestyle coach. Those allocated to the control condition received psychiatric treatment and assessment and referral, if indicated, for medical problems. A mixed-effects model was used to examine the impact of the interventions on body mass index (BMI). Exploratory moderator analyses were used to characterize those individuals likely to benefit from each treatment approach.Analyses were conducted on data for the IRRI (n = 58) and control (n = 56) participants with ≥ 1 study visit. IRRI was associated with a significantly greater rate of decrease in BMI (d = -0.51, 95% confidence interval: -0.91 to -0.14). Three variables (C-reactive protein, total cholesterol, and instability of total sleep time) contributed to a combined moderator of faster decrease in BMI with IRRI treatment.Overweight/obese patients with bipolar disorder can make modest improvements in BMI, even when taking medications with known potential for weight gain. Our finding that a combination of three baseline variables provides a profile of patients likely to benefit from IRRI will need to be tested further to evaluate its utility in clinical practice.

All living organisms depend on homeostasis, the complex set of interacting metabolic chemical reactions for maintaining life and well-being. This is no less true for psychiatric well-being than for physical well-being. Indeed, a focus on homeostasis forces us to see how inextricably linked mental and physical well-being are. This paper focuses on these linkages. In particular, it addresses the ways in which understanding of disturbed homeostasis may aid in creating classes of patients with mood and anxiety disorders based on such phenotypes. At the cellular level, we may be able to compensate for the inability to study living brain tissue through the study of homeostatic mechanisms in fibroblasts, pluripotent human cells, and mitochondria and determine how homeostasis is disturbed at the level of these peripheral tissues through exogenous stress. We also emphasize the remarkable opportunities for enhancing knowledge in this area that are offered by advances in technology. The study of human behavior, especially when combined with our greatly improved capacity to study unique but isolated populations, offers particularly clear windows into the relationships among genetic, environmental, and behavioral contributions to homeostasis.

Founded in 2005, the Cities of Peace Initiative, located in New York, has included young artist interns, scholars, and experts from more than 25 countries who, through collaborative work, have created nine Cities of Peace paintings that honor the history and culture of world cities that have suffered trauma. In 2015, Cities of Peace was invited to the 70th Commemoration of the Liberation of Auschwitz-Birkenau; also in 2015, Cities of Peace was invited by the former Prime Minister of Armenia, now Rector of the Russian-Armenian (Slavonic) University (RAU), to create the 10th Cities of Peace painting in Yerevan on the occasion of the 100th Anniversary of Armenian Genocide. This marks a substantial shift in program: working in the actual city with the citizens - students, artists, scholars, and museum directors - being honored. The rich success and vitality of the work in Auschwitz and in Yerevan attest to the power of art created in historic or current conflict zones. This paper explores the elements that contributed to the spirit and success of the Cities of Peace Initiative in these locations and establishes goals for its continuing growth, as an international peacebuilding modality, and in architecting a new cultural diplomacy through the transformational power of illuminated art. Resumen Fundada en el año 2005, la Iniciativa Ciudades de Paz (Cities of Peace ®), con sede en Nueva York, ha incluido desde su inicio pasantías y residencias de jóvenes artistas, académicos y expertos venidos de más de 25 países, quienes -a través del trabajo colaborativo- han creado nueve Obras Pictóricas de Ciudades de Paz, que honran la historia, la memoria y la cultura de ciudades del mundo que han sufrido los traumas de la guerra. Así, en el año 2015, Ciudades de Paz fue invitado especial para la septuagésima conmemoración de la liberación del campo de concentración de Auschwitz-Birkenau; También en 2015, Ciudades de Paz recibió invitación del entonces primer ministro de Armenia, hoy rector de la Universidad Eslava Armenio-Rusa (RAU) para crear la décima obra pictórica de la iniciativa Ciudades de Paz, esta vez en Ereván, con motivo de la centésima conmemoración del Genocidio Armenio. Con esto se da un cambio de enfoque sustancial en el programa: en adelante se hace la obra en la ciudad misma que está siendo motivo del homenaje, trabajando junto con sus ciudadanos, estudiantes, artistas, académicos y directores de museos. El éxito rotundo y la vitalidad de las obras realizadas en Auschwitz y en Ereván atestiguan del poder del arte creado en zonas de conflicto histórico o actual. Este artículo explora los elementos que contribuyeron al espíritu y al éxito de la Iniciativa Ciudades de Paz en estos lugares, mientras establece nuevas metas para continuar su desarrollo y aumentar su poder de influencia como una modalidad de construcción internacional de paz, creando así el andamiaje y la estructura de una nueva forma de diplomacia cultural, articulada a través del poder transformador de un arte reflexivo y capaz de iluminar. Resumo Fundada no ano de 2005, a iniciativa Cidades de Paz (Cities of Peace ®), com sede em Nova Iorque, tem incluído desde seu inicio estágios e residências de jovens artistas, acadêmicos e expertos vindos de mais de 25 países, quem -por meio do trabalho colaborativo- tem criado nove Obras Pictóricas de Cidades de Paz, que honram a historia, a memória e a cultura de cidades do mundo que tem sofrido os traumas da guerra. Assim, no ano 2015, Cidades de Paz foi convidado especial para a septuagésima comemoração da liberação do campo de concentração de Auschwitz-Birkenau; também em 2015, Cidades de Paz recebeu convite do Primeiro ministro (naquele momento) de Armênia, e hoje reitor da Universidade Eslava Armênio-Russa (RAU) para criar a décima obra pictórica da iniciativa Cidades em Paz, nesta vez em Ereván, com motivo da centésima comemoração do Genocídio Armênio. Com isto faz-se uma mudança de perspectiva substancial no programa: em diante se faz a obra na cidade mesma que esta sendo motivo de homenagem, trabalhando junto com seus cidadãos, estudantes, artistas, acadêmicos e diretores de museus. O sucesso absoluto e a vitalidade das obras realizadas em Auschwitz e em Ereván dão testemunha do poder da arte feita em lugares de conflito histórico ou atual. Este artigo explora os elementos que contribuíram ao espírito e ao sucesso da Iniciativa Cidades de Paz nestes lugares, enquanto se estabelecem novos alvos para continuar seu desenvolvimento e aumentar seu poder de influencia como uma modalidade de construção internacional de paz, criando assim a estrutura e a organização de uma nova forma de diplomacia cultural, articulada por meio do poder transformador de uma arte reflexiva e capaz de iluminar.

Study Objectives The mechanisms linking short sleep duration to cardiovascular disease (CVD) are poorly understood. Emerging evidence suggests that endothelial dysregulation may lie along the causal pathway linking sleep duration to cardiovascular risk, although current evidence in humans is based on cross-sectional studies. Our objective was to evaluate the prospective association between objectively assessed sleep duration and clinical indices of endothelial health. Methods A total of 141 medically healthy adults underwent an overnight laboratory sleep study when they were between the ages of 21 and 60 years. Total sleep time was objectively assessed by polysomnography at study entry. Endothelial health, including brachial artery diameter (BAD) and flow-mediated dilation (FMD), was measured 18.9 ± 4.6 years later. Medical health and psychiatric status were assessed at both time points. Approximately half of the sample had a lifetime history of major depressive disorder. Results In univariate analyses, shorter sleep duration was associated with increased BAD (β = -0.24, p = .004) and decreased FMD (β = 0.17, p = .042). BAD, but not FMD, remained significantly associated with sleep duration after adjusting for sex, age, body mass index (BMI), smoking, diabetes, hypertension, and lifetime history of major depressive disorder (MDD) at T2. The association between sleep duration and BAD was stronger than the association between BAD and an aggregate measure of CVD risk including three or more of the following risk factors: male sex, age ≥ 65 years, smoker, BMI ≥ 30, diabetes, hypertension, and MDD. Conclusions Objectively assessed short sleep duration was prospectively associated with increased BAD over a 12- to 30-year period.

We employed standard literature search techniques and surveyed participants on the International Society for Interpersonal Psychotherapy listserve (isipt-list@googlegroups.com) to catalogue the multiple and highly creative ways in which Klerman’s and Weissman’s original concept of interpersonal psychotherapy (IPT) has been modified to meet the needs of a vast range of patient populations. Focusing first on adaptations of the individual treatment model for subgroups of adult patients, we next describe further adaptations of four major off-shoots of IPT: interpersonal counseling (IPC), IPT for adolescents (IPT-A), group IPT (IPT-G) and most recently, brief IPT (IPT-B). We then discuss IPT “in-laws,” those treatments that have married IPT with of other forms of psychotherapy for patients with bipolar disorder, panic symptomatology, and substance abuse. We conclude with that although there have been myriad successful adaptations of IPT, there remain some conditions for which IPT adaptations have not been found to be efficacious.

Objective: We demonstrate the utility of the time-varying effect model (TVEM) for the analysis of psychotherapy data, with the aim of elucidating complex patterns of change over time and dynamic associations between constructs of interest. Specifically, we examine the association between depression and co-occurring anxiety in a sample of adults treated with interpersonal psychotherapy (IPT) for depression or a variant designed to address both depression and co-occurring anxiety (IPT-PS, IPT for depression with panic and anxiety symptoms). Method: Seventy-eight (82% female) adult outpatients with major depression and co-occurring anxiety were assessed at each of 16 outpatient treatment sessions using the Hamilton rating scales for depression and anxiety. Results: On average, depressive symptoms declined in a quadratic form over the course of treatment. While the association between anxiety and depression was modest early in treatment, it strengthened over the middle and latter treatment phases. Finally, exploratory analyses suggest that while IPT and IPT-PS were similarly effective in reducing depressive symptoms, IPT-PS may be more effective at uncoupling the association between core anxiety and depressive symptoms. Conclusions: Findings point to the utility of the TVEM for psychotherapy research and the importance of assessing anxiety in the course of treating depression, especially following the initial phase of treatment (i.e., after Session 5).

Interpersonal and Social Rhythm Therapy (IPSRT) delays bipolar disorder (BP) recurrence in adults by stabilizing daily routines and sleep/wake cycles. Because adolescence is a key developmental stage for illness onset and altered social and sleep patterns, this period may prove optimal for intervention with adolescents at-risk for BP. We describe a treatment development trial of IPSRT for adolescents at-risk for BP by virtue of a positive family history. Adolescents with a first-degree relative with BP were evaluated for Axis I psychopathology via semistructured interview, and relatives' BP diagnoses were confirmed via record review. IPSRT consisted of 12 sessions delivered over 6 months. Outcome variables including sleep, mood symptoms, and functioning were assessed via clinician interview and self-/parent-report at pretreatment, 3 months, and posttreatment (6 months). Thirteen adolescents attended at least one IPSRT session. Half of the sample denied Axis I psychopathology at intake; the remainder met criteria for a range of internalizing and externalizing disorders. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BP illness severity. Data indicate significant change in select sleep/circadian patterns (i.e., less weekend sleeping in and oversleeping) with treatment. Preliminary data suggest the IPSRT focus on stabilizing daily rhythms and interpersonal relationships may be beneficial for adolescents at-risk for BP. Controlled trials with longitudinal follow-up are needed to examine whether early intervention for at-risk youth helps prevent or delay disorder.

CME Educational Objectives 1. Understand the various stressors experienced by college students. 2. Learn how stress, resilience, and mental health in college are interrelated. 3. Explore how resilience education can improve the mental health of college students. The transition to college can be an exciting, albeit stressful, time in students’ lives, as many begin living apart from family and friends for the first time and must adapt to new and increasingly demanding academic, social, and financial pressures while adjusting to life in an unfamiliar environment. As a result of this transition, first-year college students tend to experience greater stress, anxiety, and psychological distress (eg, depression) relative to upperclassmen. 1 The extent to which students are able to cope with stressors during the first year of college has important implications not only for their social-emotional adjustment, but also for the likelihood of their academic success and persistence in postsecondary education. 2

Circadian clocks are temporal interfaces that organize biological systems and behavior to dynamic external environments. Components of the molecular clock are expressed throughout the brain and are centrally poised to play an important role in brain function. This paper focuses on key issues concerning the relationship among circadian clocks, brain function, and development, and discusses three topic areas: (1) sleep and its relationship to the circadian system; (2) systems development and psychopathology (spanning the prenatal period through late life); and (3) circadian factors and their application to neuropsychiatric disorders. We also explore circadian genetics and psychopathology and the selective pressures on the evolution of clocks. Last, a lively debate is presented on whether circadian factors are central to mood disorders. Emerging from research on circadian rhythms is a model of the interaction among genes, sleep, and the environment that converges on the circadian clock to influence susceptibility to developing psychopathology. This model may lend insight into effective treatments for mood disorders and inform development of new interventions.

In a large, prospective, 8-week open study of 721 outpatients receiving agomelatine treatment for a current major depressive episode (MDE), morningness-eveningness (Composite Scale of Morningness) was assessed before and after treatment to investigate possible changes in morningness-eveningness after treatment and evaluate whether morningness-eveningness at baseline predicted treatment response. A change towards morningness was observed after treatment. This change was greater in responders than non-responders. Moreover, being a morning type at baseline was an independent predictor of response to treatment. Once thought to be a trait variable, morningness-eveningness is a potential treatment target that should be systematically assessed in MDE patients.

The goal of this study was to compare five actigraphy scoring methods in a sample of 18 remitted patients with bipolar disorder. Actigraphy records were processed using five different scoring methods relying on the sleep diary; the event-marker; the software-provided automatic algorithm; the automatic algorithm supplemented by the event-marker; visual inspection (VI) only. The Algorithm and the VI methods differed from the other methods for many actigraphy parameters of interest. Particularly, the Algorithm method yielded longer sleep duration, and the VI method yielded shorter sleep latency compared to the others methods. The present findings provide guidance for the selection of signal processing method based on sleep parameters of interest, time-cue sources and availability, and related scoring time costs for the study.