Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older. STUDY SELECTION: We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013. DATA EXTRACTION: We abstracted relevant data, assessed each study's internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates. RESULTS: rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear. CONCLUSIONS: For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.

Comparative effectiveness of interventions for children exposed to nonrelational traumatic events.

OBJECTIVES: To assess the effectiveness of interventions targeting traumatic stress among children exposed to nonrelational traumatic events (eg, accidents, natural disasters, war). METHODS: We assessed research on psychological and pharmacological therapy as part of an Agency for Healthcare Research and Quality-commissioned comparative effectiveness review. We conducted focused searches of Medline, Cochrane Library, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, and Web of Science. Two trained reviewers independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We used qualitative rather than quantitative analysis methods because of statistical heterogeneity, insufficient numbers of similar studies, and variation in outcome reporting. RESULTS: We found a total of 21 trials and 1 cohort study of medium or low risk of bias from our review of 6647 unduplicated abstracts. We generally did not find studies that attempted to replicate findings of effective interventions. In the short term, no pharmacotherapy intervention demonstrated efficacy, and only a few psychological treatments (each with elements of cognitive behavioral therapy) showed benefit. The body of evidence provides little insight into how interventions to treat children exposed to trauma might influence healthy long-term development. CONCLUSIONS: Our findings serve as a call to action: Psychotherapeutic intervention may be beneficial relative to no treatment in children exposed to traumatic events. Definitive guidance, however, requires far more research on the comparative effectiveness of interventions targeting children exposed to nonrelational traumatic events.

The role of public schools in HIV prevention: perspectives from African Americans in the rural South.

Though African-American youth in the South are at high risk for HIV infection, abstinence until marriage education continues to be the only option in some public schools. Using community-based participatory research methods, we conducted 11 focus groups with African-American adults and youth in a rural community in North Carolina with high rates of HIV infection with marked racial disparities. Focus group discussions explored participant views on contributors to the elevated rates of HIV and resources available to reduce transmission. Participants consistently identified the public schools' sex education policies and practices as major barriers toward preventing HIV infection among youth in their community. Ideas for decreasing youth's risk of HIV included public schools providing access to health services and sex education. Policymakers, school administrators, and other stakeholders should consider the public school setting as a place to provide HIV prevention education for youth in rural areas.

The Impact of Children's Social Adjustment on Academic Outcomes.

This study tested whether social adjustment added to the prediction of academic outcomes above and beyond prior academic functioning. School records and peer-, teacher-, and self-report measures were collected for 1,255 third grade children in the fall and spring of the school year. Social acceptance by and aggression with peers were included as measures of social adjustment. Academic outcomes included math and reading GPA, classroom behavior, academic self-esteem, and absenteeism. As expected, support for the causal model was found where both forms of social adjustment contributed independently to the prediction of each area of academic adjustment. Gender differences in the patterns of results were present, particularly for the impact of aggression on academic adjustment. Discussion focuses on the implications for social-emotional literacy programs to prevent negative academic outcomes.

Understanding social capital and HIV risk in rural African American communities.

BACKGROUND: African Americans (AA) and rural communities often suffer disproportionately from poorer health. Theory-guided research examining how individual- and community-level factors influence health behaviors and contribute to disparities is needed. OBJECTIVE: To understand how a social network model that captures the interplay between individual and community factors might inform community-based interventions to reduce HIV risk in rural AA communities. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Eleven focus groups with 38 AA 16-24 year olds, 42 adults over age 25, and 13 formerly incarcerated individuals held in community settings in two rural, predominantly AA counties in North Carolina. Thirty-seven semi-structured interviews with multiethnic key informants. APPROACH: Semi-structured interviews and focus groups with open-ended questions assessed a) perceptions of multi-level HIV risk determinants from a social network model (individual, interpersonal, social, economic, political and structural) identified through literature review and b) community needs and assets affecting local HIV rates. Qualitative data was analyzed using directive content analysis guided by a social network model. RESULTS: We identified four themes regarding the interaction between individuals and their communities that mediate HIV risk: interpersonal processes, community structural environment, social disorder, and civic engagement. Communities were characterized as having a high degree of cohesiveness, tension, and HIV-related stigma. The community structural environment-characterized by neighborhood poverty, lack of skilled jobs, segregation, political disenfranchisement and institutional racism-was felt to reduce the availability and accessibility of resources to combat HIV. Adults noted an inability to combat social problems due to social disorder, which fuels HIV risk behaviors. Civic engagement as a means of identifying community concerns and developing solutions is limited by churches' reluctance to address HIV-related issues. CONCLUSION: To combat HIV-related stigma, physicians should follow recommendations for universal HIV testing. Besides asking about individual health behaviors, physicians should ask about the availability of support and local community resources. Physicians might consider tailoring their treatment recommendations based on available community resources. This strategy may potentially improve patient adherence and clinical outcomes.

Project GRACE: a staged approach to development of a community-academic partnership to address HIV in rural African American communities.

The HIV epidemic is a health crisis in rural African American communities in the Southeast United States; however, to date little attention has been paid to community-academic collaborations to address HIV in these communities. Interventions that use a community-based participatory research (CBPR) approach to address individual, social, and physical environmental factors have great potential for improving community health. Project GRACE (Growing, Reaching, Advocating for Change and Empowerment) uses a CBPR approach to develop culturally sensitive, feasible, and sustainable interventions to prevent the spread of HIV in rural African American communities. This article describes a staged approach to community-academic partnership: initial mobilization, establishment of organizational structure, capacity building for action, and planning for action. Strategies for engaging rural community members at each stage are discussed; challenges faced and lessons learned are also described. Careful attention to partnership development has resulted in a collaborative approach that has mutually benefited both the academic and community partners.

Studying genetic research participants: lessons from the "Learning About Research in North Carolina" study.

Given the prohibitive cost of recruiting large and diverse populations for genetic explorations in cancer research, there has been a call for genetic studies to engage existing cohorts of research participants. This strategy could lead to more efficient recruitment and potentially result in significant advances in the understanding of cancer etiology and treatment. The Learning About Research in North Carolina (LeARN) study responded to the National Human Genome Research Institute interest in research on how study participants from diverse populations who had participated in genetic research perceived the risks and benefits of participating in combined epidemiologic-genetic research, how well they understand the purpose of the research and the uses to which the research results may be put, and how involvement in such research affects perceptions of disease causality. In this article, we give an overview of the LeARN study, summarizing the methods we used, challenges we encountered, and lessons learned about recruiting participants who have previously participated in genetic research.