The Utility of Meditation and Mindfulness-Based Interventions in the Time of COVID-19: A Theoretical Proposition and Systematic Review of the Relevant Prison, Quarantine and Lockdown Literature.

As of July 20, 2021, Covid-19 has killed 4,086,000 people, infected at least 190,169,833 others, and devastated the world's economy. To slow the spread of the virus, numerous governments instituted "lockdown" policies and quarantines, limiting social interactions to the immediate household. The experience of isolation and uncertainty have contributed to increased fear, anxiety, and loneliness; with limited options of research-supported interventions. Although different in nature, the experiences of quarantine and lockdown have been likened to incarceration. Past research has found meditation and mindfulness-based interventions (MBIs) to be effective psychological treatments for prisoners and may therefore translate well into effective methods for the maintenance of psychological well-being for individuals quarantined during the pandemic. More recently, research investigating the effects of meditation and MBIs during the pandemic have demonstrated preliminary evidence for beneficial psychological improvements. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), the current narrative review paper: 1) examines the parallels and differences between the experience of quarantine and imprisonment, 2) investigates the mechanisms through which meditation and mindfulness enact their effects, and 3) systematically reviews literature on the benefits of various types of meditation and MBIs for inmates and individuals in lockdown or quarantine. With this knowledge, the public can garner applicable insight into the potential use of meditation and MBIs for individuals forced to cope with pandemic lockdowns and quarantines. Two hundred and twenty one (221) articles were identified through Pubmed and Google Scholar, and 24 articles were ultimately included in the manuscript.

Childhood Environmental Instability and Social-Emotional Outcomes in Emerging Adults.

Adverse childhood experiences (ACEs) can negatively affect social-emotional functioning. The association between individual and cumulative ACEs and social-emotional domains of self-esteem, loneliness, and negotiation in intimate partner relationships has not been explored in low-risk emerging adults, a gap this study aims to fill. An online survey was administered to undergraduate emerging adults, ages 18 to 25 years (Mage = 19.73, SD = 1.83; N = 436; 20.60% Hispanic; 63.80% female). The ACEs Survey, Child Abuse Potential Inventory, and Conflict Tactics Scale-2nd Edition were used. Three multivariate ordinary least squares regressions were run, each including predictors significant in bivariate analyses and outcomes of self-esteem, loneliness, and negotiation for each regression. Emotional abuse, B = -.20, p < .01; emotional neglect, B = -.21, p < .001; and substance using family member, B = -.12, p < .05, were negatively associated with self-esteem; emotional neglect, B = .11, p < .01, and cumulative ACEs, B = .16, p < .01, were positively associated with loneliness; and incarcerated family member was positively associated with negotiation, B = .12, p < .05. Overall, these findings suggest that individual ACEs associated with environmental instability (e.g., emotional abuse) are strong predictors of social-emotional outcomes, relative to ACEs associated with more direct physical harm (e.g., sexual abuse).

The association between COVID-19-related stressors and mental health outcomes for survivors of past interpersonal and non-interpersonal trauma.

The mental health difficulties of trauma survivors during the COVID-19 pandemic have been under-reported. This study explored the moderating role of trauma history and trauma type (interpersonal and non-interpersonal) in the association between COVID-19-related stressors and depression, anxiety, and stress. A sample of n = 321 participants ages 19 to 71 (M = 36.63, SD = 10.36) was recruited from across the United States through MTurk. Participants reported the number of COVID-19-related stressors, trauma history and psychological symptoms. Hierarchical multiple regression analyses, controlling for age, race, ethnicity, gender, education, and income levels, were used to determine (a) whether COVID-19-related stressors are associated with adverse mental health outcomes; (b) whether trauma history and (c) trauma type moderated this association. Results revealed significant interactions; for those with a trauma history, exposure to COVID-19-related stressors was associated with higher levels of depression (ß = .21, p < .05) and anxiety (ß = .19, p < .05). For those with a history of interpersonal trauma specifically, COVID-19-related stressors were associated with depression (ß = .16, p < .05) more so than for those without a trauma history. These findings highlight the vulnerability of trauma survivors to the unprecedented COVID-19-related stress.

Sexual Victimization Disclosure: A Cluster Analysis Approach to Understanding Victimization Experiences in Disclosers and Non-Disclosers.

Research has used cluster analysis to identify clusters, or groups, of sexual victimization survivors who share similar assault experiences. However, researchers have not investigated whether disclosure status is a key component of the survivors' experience. The current study identified two clusters among 174 disclosing and non-disclosing sexual victimization survivors. Cluster One (n = 74) included an incapacitated assault by a lesser-known perpetrator and disclosure of the event. Cluster Two (n = 100) included a verbally instigated assault by a well-known perpetrator and nondisclosure of the event. Follow up independent t-tests revealed that women in Cluster One had significantly higher depression and posttraumatic stress disorder (PTSD) symptoms than women in Cluster Two. Results support prior research identifying clusters of victimization based on assault characteristics and suggest that disclosure status is a key variable in the recovery process. Specific implications for clinicians, policy makers, and the community are discussed.

Why Do Women Talk About It? Reasons for Disclosure of Sexual Victimization and Associated Symptomology.

Many sexual victimization survivors disclose their experience; however, there is limited research investigating why women disclose this experience and how reasons relate to psychopathology. The current online study aims to further understand the experiences of 142 female survivors (aged 18-29 years) by identifying their reason for disclosure and investigating how reasons relate to self-reported depression and post-traumatic stress disorder (PTSD) symptomology. Qualitative analyses identified two reasons: intentional and elicited disclosures. Hierarchical linear regressions revealed that elicited disclosures were associated with higher PTSD symptomology than intentional disclosures above and beyond relevant covariates, suggesting that disclosure reason is an important factor in the recovery process.

Is There a Cumulative Association Between Adverse Childhood Experiences and Intimate Partner Violence in Emerging Adulthood?

Adverse childhood experiences (ACEs) have been shown to cumulatively predict a range of poor physical and mental health outcomes across adulthood. The cumulative effect of ACEs on intimate partner violence (IPV) in emerging adulthood has not been previously explored. The current study examined the individual and cumulative associations between nine ACEs (emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, witnessing domestic violence, living with a mentally ill, substance abusing, or incarcerated household member) and IPV in a diverse sample of college students (N = 284; Mage = 20.05 years old [SD = 2.5], 32% male, 37% Caucasian, 30% Asian, 33% other, and 27% Hispanic) from an urban, public college in the Northeast of the United States. Participants reported ACEs (measured by the Adverse Childhood Experiences Survey) and IPV perpetration and victimization (measured with the Revised Conflict Tactics Scale-2) of physical and psychological aggression in an online study that took place from 2015 to 2016. Bivariate and multivariate associations between ACEs, cumulative ACEs (assessed by the sum of adverse experiences), and IPV outcomes were assessed, while controlling for demographics and socioeconomic status. No cumulative associations were observed between ACEs and any of the IPV subscales in multivariate regressions, while witnessing domestic violence was significantly associated with perpetration and victimization of physical aggression and injury, and household member incarceration and physical abuse were associated with physical aggression perpetration. Adverse childhood events do not seem to associate cumulatively with IPV in emerging adulthood and the contributions of individual childhood experiences appear to be more relevant for IPV outcomes. Clinical and research implications are discussed.

Risk-Taking Propensity and Sensation Seeking in Survivors of Adverse Childhood Experiences.

Risk-taking propensity and sensation seeking are developmentally meaningful traits for emerging adults, individuals ages 18 to 25 years. Adverse childhood experiences (ACEs) of childhood abuse and neglect, exposure to domestic violence, residing with a substance abusing or mentally ill caregiver, and growing up with an incarcerated family member negatively impact the well-being of emerging adults. However, the specific association between ACEs and risk-taking propensity and sensation seeking has not been previously examined in this age group. This study aims to determine whether ACEs are individually or cumulatively related to risk-taking propensity (assessed by the Domain-Specific Risk-Taking Scale) and sensation seeking (assessed by the Behavior Inhibition System/Behavior Approach System Scales) in a diverse sample of undergraduates, n = 436; Mage = 19.73 years (SD = 1.83 years); 67% female; 22% Hispanic. Multivariate ordinary least squares regressions were run to examine the association between ACEs and risk-taking propensity and sensation seeking. Individually, emotional abuse predicted greater inhibition (B = .28, p < .001), growing up with a mentally ill family member (B = -.12, p < .05) and emotional neglect (B = -.13, p < .05) predicted reduced motivation to pursue rewarding cues, and emotional neglect (B = -.12, p < .05) and witnessing domestic violence (B = -.10, p < .05) predicted less reward responsiveness. No cumulative effects were found. ACEs related to environmental instability may have a unique impact on sensation seeking domains in emerging adults. Clarifying the role of sensation seeking in emerging adults can contribute to better understanding of risk and resilience factors in this vulnerable population.

Childhood maltreatment and lead levels in middle adulthood: A prospective examination of the roles of individual socio-economic and neighborhood characteristics.

BACKGROUND: Lead is a common environmental hazard because of its past use as an additive to gasoline and household paint. Some evidence suggests that children with histories of child abuse and neglect are at elevated risk for residence in communities and households with less desirable characteristics and high levels of exposure to environmental hazards and toxins. OBJECTIVES: To understand whether childhood maltreatment leads to higher levels of household dust lead and blood lead in adulthood and the extent to which characteristics of a person's physical environment or individual level socio-economic status (SES) (based on unemployment, poverty, and receipt of public assistance) contribute to understanding the relationship. METHODS: A large prospective cohort design study in which abused and neglected children (ages 0-11) were matched with non-maltreated children and assessed in adulthood. Objective and subjective neighborhood characteristics were assessed at approximate age 40 and household dust lead (cleaned and less often cleaned) and blood lead levels were measured at age 41. Blood was collected through venipuncture by a registered nurse as part of a medical status exam. RESULTS: Childhood maltreatment predicted higher levels of dust lead in less often cleaned household places, residence in worse neighborhoods defined by objective (census tract data) and subjective (reports of physical disorder and lack of social cohesion and control), and higher levels of poverty, receiving public assistance, and unemployment. Only objective neighborhood characteristics mediated the relationship between childhood maltreatment and dust lead level in adulthood. There were also significant paths from objective neighborhood disadvantage and individual level SES to higher levels of blood lead. DISCUSSION: Thirty years after their childhood experiences, individuals with documented histories of childhood maltreatment are at higher risk for living in environments as adults with elevated lead levels that may impact other aspects of their lives and compromise their health.

Why Women Are Not Talking About It: Reasons for Nondisclosure of Sexual Victimization and Associated Symptoms of Posttraumatic Stress Disorder and Depression.

Disclosure of traumatic experiences is typically encouraged and associated with positive outcomes. However, there is limited research on nondisclosure of sexual trauma and consequent symptomology. This online study of undergraduate females examines reasons for nondisclosure and associated symptoms of posttraumatic stress disorder (PTSD) and depression. Of 221 participants who reported sexual victimization, 25% had not previously disclosed it. Four reasons for nondisclosure were identified: shame, minimization of experience, fear of consequences, and privacy. Nondisclosers who minimized the experience and nondisclosers low on shame reported fewer PTSD symptoms than disclosers. These findings suggest that reasons for nondisclosure are associated with symptomology.

The Electrical Aftermath: Brain Signals of Posttraumatic Stress Disorder Filtered Through a Clinical Lens.

This review aims to identify patterns of electrical signals identified using electroencephalography (EEG) linked to posttraumatic stress disorder (PTSD) diagnosis and symptom dimensions. We filter EEG findings through a clinical lens, evaluating nuances in findings according to study criteria and participant characteristics. Within the EEG frequency domain, greater right than left parietal asymmetry in alpha band power is the most promising marker of PTSD symptoms and is linked to exaggerated physiological arousal that may impair filtering of environmental distractors. The most consistent findings within the EEG time domain focused on event related potentials (ERPs) include: 1) exaggerated frontocentral responses (contingent negative variation, mismatch negativity, and P3a amplitudes) to task-irrelevant distractors, and 2) attenuated parietal responses (P3b amplitudes) to task-relevant target stimuli. These findings suggest that some individuals with PTSD suffer from attention dysregulation, which could contribute to problems concentrating on daily tasks and goals in lieu of threatening distractors. Future research investigating the utility of alpha asymmetry and frontoparietal ERPs as diagnostic and predictive biomarkers or intervention targets are recommended.

Negative Responses to Disclosure of Sexual Victimization and Victims' Symptoms of PTSD and Depression: The Protective Role of Ethnic Identity.

College-aged women experience high rates of sexual victimization. Their postassault symptoms are associated with the types of responses they receive from the people to whom they disclose these experiences. Negative responses are pervasive and associated with poorer outcomes. The current study examined whether a strong sense of ethnic identity and comfort with the mainstream culture moderate the association between negative responses to the first disclosure of sexual victimization and symptoms of posttraumatic stress disorder (PTSD) and depression. A diverse sample (10% Black/African American, 51% White, 39% Other, and 66% Hispanic) of undergraduate women was recruited from two urban, Eastern United States universities for this online study. Participants reported histories of sexual victimization, demographics, responses to sexual assault disclosure (i.e., victim blame, treating the victim differently, taking control, distraction, and egocentric reactions), symptoms of PTSD and depression, and their ethnic identity and mainstream cultural comfort. Thirty-seven percent (n = 221) endorsed an experience of sexual victimization, and 165 disclosed it to someone. Hierarchical ordinary least squares regressions revealed that a stronger sense of ethnic identity was associated with fewer symptoms of PTSD for those women who experienced higher levels of control, distraction, and egocentric responses from the first disclosure recipient. A strong sense of affiliation with the mainstream culture did not protect survivors who reported receiving negative responses to disclosure against symptoms of PTSD or depression. Ethnic affiliation may protect women against PTSD when they receive high levels of negative messages about sexual victimization experiences.

Higher Levels of Intelligence and Executive Functioning Protect Maltreated Children Against Adult Arrests: A Prospective Study.

Research shows that maltreated children are at elevated risk of arrest as adults and that higher verbal intelligence, reading ability, and executive functioning (abstract reasoning and cognitive flexibility) may be protective against criminal behavior. The current study examines this hypothesis using data from court-substantiated cases of child abuse and neglect and demographically matched controls followed prospectively into middle adulthood ( N = 1,196). At age 29, verbal intelligence was assessed with the Quick Test and reading ability with the Wide Range Achievement Test-Revised. At age 41, abstract reasoning was assessed with the Matrix Reasoning Test and cognitive flexibility with the Trail Making Test-B. Arrest records were gathered from law enforcement agencies through mean age 51. Data were analyzed with binomial logistic regressions. The results indicated that maltreated children were at increased risk of arrest for nonviolent and violent crime. Higher verbal intelligence, reading ability, nonverbal reasoning, and cognitive flexibility were protective against arrest for violent crime. The protective effects of neuropsychological functions were more pronounced for violent than nonviolent crime, for the control than maltreated children, and differed by gender and race. These results suggest that interventions targeting improved cognitive and neuropsychological functions may serve an important role in reducing risk of crime.

Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication.

During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.

Prescription Drug Diversion: Predictors of Illicit Acquisition and Redistribution in Three U.S. Metropolitan Areas.

OBJECTIVE: Prescription drug diversion, the transfer of prescription drugs from lawful to unlawful channels for distribution or use, is a problem in the United States. Despite the pervasiveness of diversion, there are gaps in the literature regarding characteristics of individuals who participate in the illicit trade of prescription drugs. This study examines a range of predictors (e.g., demographics, prescription insurance coverage, perceived risk associated with prescription drug diversion) of membership in three distinct diverter groups: individuals who illicitly acquire prescription drugs, those who redistribute them, and those who engage in both behaviors. METHODS: Data were drawn from a cross-sectional Internet study (N = 846) of prescription drug use and diversion patterns in New York City, South Florida, and Washington, D.C.. Participants were classified into diversion categories based on their self-reported involvement in the trade of prescription drugs. Group differences in background characteristics of diverter groups were assessed by Chi-Square tests and followed up with multivariate logistic regressions. RESULTS: While individuals in all diversion groups were more likely to be younger and have a licit prescription for any of the assessed drugs in the past year than those who did not divert, individuals who both acquire and redistribute are more likely to live in New York City, not have prescription insurance coverage, and perceive fewer legal risks of prescription drug diversion. CONCLUSION: Findings suggest that predictive characteristics vary according to diverter group.

A Prospective Examination of the Mechanisms Linking Childhood Physical Abuse to Body Mass Index in Adulthood.

Previous research has reported associations between childhood physical abuse and body mass index (BMI) in adulthood. This article examined the role of four potential mediators (anxiety, depression, posttraumatic stress, and coping) hypothesized to explain this relationship. Using data from a prospective cohort design, court-substantiated cases of childhood physical abuse (N = 78) and nonmaltreated comparisons (N = 349) were followed up and assessed in adulthood at three time points (1989-1995, 2000-2002, and 2003-2005) when participants were of age 29.2, 39.5, and 41.2, respectively. At age 41, average BMI of the current sample was 29.97, falling between overweight and obese categories. Meditation analyses were conducted, controlling for age, sex, race, smoking, and self-reported weight. Childhood physical abuse was positively associated with subsequent generalized anxiety, major depression, and post-traumatic stress disorder symptoms at age 29.2 and higher levels of depression and posttraumatic stress predicted higher BMI at age 41.2. In contrast, higher levels of anxiety predicted lower BMI. Coping did not mediate between physical abuse and BMI. Anxiety symptoms mediated the relationship between physical abuse and BMI for women, but not for men. These findings illustrate the complexity of studying the consequences of physical abuse, particularly the relationship between psychiatric symptoms and adult health outcomes.

Do race, neglect, and childhood poverty predict physical health in adulthood? A multilevel prospective analysis.

Childhood neglect and poverty often co-occur and both have been linked to poor physical health outcomes. In addition, Blacks have higher rates of childhood poverty and tend to have worse health than Whites. This paper examines the unique and interacting effects of childhood neglect, race, and family and neighborhood poverty on adult physical health outcomes. This prospective cohort design study uses a sample (N=675) of court-substantiated cases of childhood neglect and matched controls followed into adulthood (M(age)=41). Health indicators (C-Reactive Protein [CRP], hypertension, and pulmonary functioning) were assessed through blood collection and measurements by a registered nurse. Data were analyzed using hierarchical linear models to control for clustering of participants in childhood neighborhoods. Main effects showed that growing up Black predicted CRP and hypertension elevations, despite controlling for neglect and childhood family and neighborhood poverty and their interactions. Multivariate results showed that race and childhood adversities interacted to predict adult health outcomes. Childhood family poverty predicted increased risk for hypertension for Blacks, not Whites. In contrast, among Whites, childhood neglect predicted elevated CRP. Childhood neighborhood poverty interacted with childhood family poverty to predict pulmonary functioning in adulthood. Gender differences in health indicators were also observed. The effects of childhood neglect, childhood poverty, and growing up Black in the United States are manifest in physical health outcomes assessed 30 years later. Implications are discussed.

Child maltreatment and executive functioning in middle adulthood: a prospective examination.

OBJECTIVE: There is extensive evidence of negative consequences of childhood maltreatment for IQ, academic achievement, and posttraumatic stress disorder (PTSD), and increased attention to neurobiological consequences. However, few prospective studies have assessed the long-term effects of abuse and neglect on executive functioning. This study examined whether childhood abuse and neglect predicts components of executive functioning and nonverbal reasoning ability in middle adulthood and whether PTSD moderates this relationship. METHOD: Using a prospective cohort design, a large sample (N = 792) of court-substantiated cases of childhood physical and sexual abuse and neglect (ages 0-11 years) and matched controls were followed into adulthood (mean age = 41 years). Executive functioning was assessed with the Trail Making Test-Part B and nonverbal reasoning was assessed with the Matrix Reasoning test. PTSD (DSM-III-R lifetime diagnosis) was assessed at age 29 years. Data were analyzed using ordinary least squares regressions, controlling for age, sex, and race, and possible confounds of IQ, depression, and excessive alcohol use. RESULTS: In multivariate analyses, childhood maltreatment overall and childhood neglect predicted poorer executive functioning and nonverbal reasoning at age 41 years, whereas physical and sexual abuse did not. A past history of PTSD did not mediate or moderate these relations. CONCLUSIONS: Childhood maltreatment and neglect specifically have a significant long-term impact on important aspects of adult neuropsychological functioning. These findings suggest the need for targeted efforts dedicated to interventions for neglected children.

Child abuse and neglect, MAOA, and mental health outcomes: a prospective examination.

BACKGROUND: Studies have examined the interaction of MAOA genotype with childhood maltreatment in relation to depressive symptomatology and alcohol abuse with conflicting findings. Both high- and low-activity allele combinations have been shown to be protective for maltreated children with direction of findings varying by study methodology and participants' sex. METHODS: Participants in a prospective cohort design study involving court-substantiated cases of child abuse and neglect and a matched comparison group were followed up into adulthood and interviewed (N = 802). Eighty-two percent consented to provide blood, 631 gave permission for DNA extraction and analyses, and 575 were included in the final sample. This sample included male, female, white, and nonwhite (primarily black) participants. Symptoms of dysthymia, major depression, and alcohol abuse were assessed using the National Institutes of Mental Health Diagnostic Interview Schedule-III-R. RESULTS: Significant three-way interactions, MAOA genotype by abuse by sex, predicted dysthymic symptoms. Low-activity MAOA genotype buffered against symptoms of dysthymia in physically abused and multiply-maltreated women. Significant three-way interactions, MAOA genotype by sexual abuse by race, predicted all outcomes. Low-activity MAOA genotype buffered against symptoms of dysthymia, major depressive disorder, and alcohol abuse for sexually abused white participants. The high-activity genotype was protective in the nonwhite sexually abused group. CONCLUSIONS: This prospective study provides evidence that MAOA interacts with child maltreatment to predict mental health outcomes. Reasons for sex differences and race findings are discussed.

The role of childhood neglect and childhood poverty in predicting mental health, academic achievement and crime in adulthood.

This study examines the roles of childhood neglect and childhood poverty (family and neighborhood) in predicting Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), academic achievement, and crime in young adulthood. Using existing data from a prospective cohort design study, 1,005 children with documented histories of neglect (N = 507) and matched controls (N = 497) were interviewed in young adulthood (mean age 29). Official criminal histories were also used to assess outcomes. Data were analyzed using logistic and ordinary least squares regressions and hierarchical linear modeling (HLM) to control for neighborhood clustering. Results from HLM revealed that childhood neglect and childhood family poverty uniquely predicted PTSD and adult arrest, MDD was predicted only by childhood family poverty, and a significant interaction between childhood family poverty and childhood neighborhood poverty predicted academic achievement for the control group only. Childhood neglect, childhood family poverty, and childhood neighborhood poverty each contribute to poor outcomes later in life. While interventions should be developed for neglected children to prevent negative outcomes, the current findings suggest that it is also important to consider the ecological context in which these children are growing up.

From efficacy to effectiveness: the trajectory of the treatment literature for children with PTSD.

This review summarizes efficacious treatments for preschoolers, children and adolescents with post-traumatic stress disorder, with a focus on the advances made within the last 5 years. There is considerable support for the use of trauma-specific cognitive-behavioral interventions, in both individual and group formats. The research on psychopharmacological treatments lags behind that of psychotherapy and is currently inconclusive. Limitations of the studies are discussed and treatments that warrant further consideration are reviewed. The authors also review current advances in effectiveness and suggest future directions that are important in generalizing the interventions to underserved and hard to reach populations. The article concludes with the authors' projections for the evolution of the field within the upcoming 5 years.