Toward Efficient, Sustainable, and Scalable Methods of Treatment Characterization: An Investigation of Coding Clinical Practice from Chart Notes.

PURPOSE: Chart notes provide a low-cost data source that could help characterize what occurs in treatment with sufficient precision to improve management of care. This study assessed the interrater reliability of treatment content coded from chart notes and evaluated its concordance with content coded from transcribed treatment sessions. METHOD: Fifty randomly selected and digitally recorded treatment events were transcribed and coded for practice content. Independent coders then applied the same code system to chart notes for these same treatment events. ANALYSIS: We measured reliability and concordance of practice occurrence and extensiveness at two levels of specificity: practices (full procedures) and steps (subcomponents of those procedures). RESULTS: For chart notes, practices had moderate interrater reliability (M k = 0.50, M ICC = 0.56) and steps had moderate (M ICC = 0.74) to substantial interrater reliability (M k = 0.78). On average, 2.54 practices and 5.64 steps were coded per chart note and 4.53 practices and 13.10 steps per transcript. Across sources, ratings for 64% of practices and 41% of steps correlated significantly, with those with significant correlations generally demonstrating moderate concordance (practice M r = 0.48; step M r = 0.47). Forty one percent of practices and 34% of steps from transcripts were also identified in the corresponding chart notes. CONCLUSION: Chart notes provide an accessible data source for evaluating treatment content, with different levels of specificity posing tradeoffs for validity and reliability, which in turn may have implications for chart note interfaces, training, and new metrics to support accurate, reliable, and efficient measurement of clinical practice.

Measurement and Correlates of Food Selection Motivations in a United States Sample.

Background: In this study, we explored the factors that motivate food choice, and evaluated the psychometric properties and demographic correlates of the Eating Motivation (EATMOT) questionnaire in adults in the United States (US). Methods: This cross-sectional survey involved 905 adults in 6 sites across the US. The EATMOT questionnaire measures participants' self-reported motivations for food selection, demographic, and anthropometric data. Analyses included exploratory and confirmatory factor analyses, correlations, Welch's t-tests, and logistic regressions. Results: We established a 3-factor model (health-related, emotional, and environmental/political motivations) as the best fit to the data (CFI = .983, RMSEA = .049, SRMR = .054). Gender differences were found within the 3 factors, as well as in the intercorrelations between factors. Higher levels of health-related motivations (B = .10, SE = .04, OR = 1.11 (95% CI: 1.03, 1.19), p = .006) were associated with increased reports of weight loss dieting, whereas higher levels of environmental/political motivations (B = -.09, SE = .04, OR = 0.91, p = .02) were associated with fewer reports of weight-loss dieting. Conclusion: An abbreviated version of the EATMOT scale is appropriate for use in a US sample and identifies 3 categories of factors that impact dietary choices. These factors may be important in building interventions to improve diets.

Early Life Adversity and Clinical Intimate Partner Violence in Adulthood: The Mediating Role of Interpersonal Conflict in Adolescence.

Intimate partner violence (IPV) is associated with adverse outcomes for both victims and perpetrators, though there is significant heterogeneity in manifestations of relationship violence. A growing amount of research has focused on elucidating predictors of clinical IPV-defined as severe violence involving institutional or medical intervention due to actual or potential injury-so as to better understand potential prevention and intervention targets. Early life adversity (ELA) is associated with IPV in adulthood, yet this literature focuses on discrete, retrospectively reported adversities (e.g., physical abuse and neglect) and has yet to consider clinical IPV as an outcome. Little is known about if and how broadly adverse early environments may confer risk for this specific form of relationship violence. We investigated associations between exposure to ELA prior to age five and clinical IPV victimization and perpetration by age 20 in a longitudinal, community-based sample of men and women in Australia (N = 588). Early life adversity was prospectively indexed by maternal reports of financial hardship, child chronic illness, maternal stressful life events, maternal depressive symptoms, parental discord, and parental separation. Youth interpersonal conflict life events at age 15-an interviewer-rated assessment of episodic stressors involving conflict across relationships in mid-adolescence-was tested as a potential mediator for both victims and perpetrators. Among women, ELA predicted IPV victimization and perpetration, and interpersonal conflict life events partially mediated the link between ELA and victimization, but not perpetration. Neither ELA nor interpersonal conflict life events predicted victimization or perpetration among men. Women exposed to ELA are at-risk for conflictual interpersonal relationships later in life, including violent intimate relationships, and deficits in conflict resolution skills may be one mechanism through which ELA leads to IPV victimization among this subgroup. Violence prevention and intervention efforts should target interpersonal skills, including conflict resolution, among women and girls exposed to adverse early environments.

Social impairment in relation to clinical symptoms in youth at high risk for bipolar disorder.

AIM: Social impairment is common in individuals with bipolar disorder (BD), although its role in youths at high-risk for BD (i.e., mood symptoms in the context of a family history of BD) is not well understood. Social impairment takes many forms including social withdrawal, relational aggression, physical aggression, and victimization. The aim of this study was to explore the links between social impairment and clinical symptoms in youth at high-risk for BD. METHODS: The sample included 127 youths with elevations in mood symptoms (depression or hypomania) and at least one first and/or second degree relative with BD. Measures of youths' current psychopathology (i.e., depressive and manic severity, suicidality, anxiety, and attention-deficit/hyperactivity disorder [ADHD]) were regressed onto youths' self-reports of social impairment (i.e., social withdrawal, relational aggression, physical aggression, and victimization). RESULTS: Depressive symptoms, suicidal ideation, and anxiety symptoms were related to social withdrawal. Suicidal ideation was also related to reactive aggression. ADHD symptoms related to reactive and proactive aggression as well as relational victimization. Manic symptoms were not associated with social impairment in this sample. CONCLUSIONS: Although cross-sectional, study findings point to potential treatment targets related to social functioning. Specifically, social withdrawal should be a target for treatment of childhood depressive and anxiety symptoms. Treatments that focus on social skills and cognitive functioning deficits associated with BD may also have clinical utility.

How much therapy is enough? The dose-response effect and its moderators in a psychology training clinic.

OBJECTIVE: The current study aims to sharpen the understanding of the psychotherapy dose-response effect and its moderators in a psychology training clinic. METHOD: Data were extracted from 58 client records. Weekly Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, as well as Outcomes Questionnaire-45.2, administered every fifth session, assessed whether clients achieved reliable change (RC) and clinically significant and reliable change (CSR) during treatment. Survival analyses were conducted to determine the sessions required for 50% of the sample to achieve these outcomes. Multilevel Cox frailty regressions were used to investigate client-and-therapy-based moderators. RESULTS: The median time for 50% of the sample to achieve RC was 8-10 sessions and 11 sessions to achieve initial CSR. Past treatment history was a significant moderator of time to achieve RC. CONCLUSIONS: From a population perspective, psychotherapy is most beneficial to patients early in treatment. Sharper understanding of the number of sessions required to achieve meaningful change can inform practice in training settings.

Inflammatory cytokines and nuclear factor-kappa B activation in adolescents with bipolar and major depressive disorders.

UNLABELLED: Adults with bipolar disorder (BD) and major depressive disorder (MDD) have higher circulating levels of proinflammatory cytokines than healthy controls. However, it is not known whether pediatric-onset patients with BD or MDD show increases in levels of inflammation or activation of nuclear factor kappa B (NF-κB), a key transcription factor in inflammatory signaling. Circulating levels of inflammatory cytokines, as well as spontaneous and stimulated levels of activated NF-κB in total peripheral blood mononuclear cells, monocytes and lymphocytes were measured in adolescents with BD (n=18), MDD (n=13), or no psychiatric history (n=20). Participants had a range of mood symptoms at time of testing. Adolescents with BD had significantly higher spontaneous levels of NF-κB in peripheral blood mononuclear cells, monocyte and lymphocyte populations, and higher plasma levels of IL-1ß than healthy controls. Following stimulation with recombinant human TNF-α, participants with BD and MDD both had greater increases in NF-κB in monocytes than controls. Further, greater stimulated increases of NF-κB in monocytes were associated with the current severity of depressive symptoms. The results are limited by the small sample and cross-sectional design. Interventions that target early immunological dysregulation should be examined in relation to long-term outcomes in youth with bipolar and depressive disorders. CLINICAL TRIAL REGISTRATION INFORMATION: Early Intervention for Youth at Risk for Bipolar Disorder, https://clinicaltrials.gov/ct2/show/NCT01483391.

Negative interpersonal events mediate the relation between borderline features and aggressive behavior: findings from a nonclinical sample of undergraduate women.

Interpersonal dysfunction and aggression are features that are frequently found in individuals with borderline personality disorder (BPD); however, few studies have examined the possible causal relationship between aggressive actions and interpersonal problems. In a nonclinical sample of 98 women with a range of BPD features, the present study examined the prospective relationship between aggressive behaviors and negative interpersonal events using a weekly diary method. Results showed that higher BPD symptoms were related to higher aggression and more negative interpersonal events. Furthermore, the aggressive acts endorsed among women with more BPD features were more likely the effect, rather than the cause, of the negative interpersonal events they experienced. Implications for interventions targeting aggression among women with elevated BPD features and suggestions for future research are discussed.

Family functioning, social impairment, and symptoms among adolescents with bipolar disorder.

OBJECTIVE: Impaired social functioning is common among youth with bipolar disorder (BD), emerges in multiple settings, and persists over time. However, little is known about factors associated with poor peer and family functioning in the early-onset form of BD. Using a sample of adolescents with BD I or II, we examined which symptoms of BD, including nonspecific symptoms such as inattention, aggression, and anxiety/depression, were associated with family functioning (adaptability, cohesion, and conflict) and peer relationship quality. METHOD: Adolescents (N = 115; 46% male) with BD I and II and their parents were evaluated before participation in a multi-site randomized controlled trial. Adolescents had experienced an episode of depression, mania, or hypomania within the previous 3 months and were not in full remission. Adolescents' problem behaviors were assessed using the parent-rated Child Behavior Checklist (CBCL). Family functioning was assessed via child- and parent-report questionnaires. RESULTS: Depressive symptoms were associated with lower child-ratings of family functioning. Contrary to hypotheses, moderate mania was associated with better parent-reported family conflict, adaptability, and cohesion. Aggression was associated with poorer family functioning across reporters and measures, even when controlling for the effects of depression, mania, and inattention. None of these symptom clusters were associated with peer functioning. CONCLUSIONS: Aggression was the strongest correlate of family functioning in pediatric BD in this cross-sectional study. Findings speak to the potential value of addressing aggression and family dysfunction in the treatment of youth with BD. Clinical trial registration information-Effectiveness of Family-Focused Treatment Plus Pharmacotherapy for Bipolar Disorder in Adolescents; http://clinicaltrials.gov/; NCT00332098.

Coaction of stress and serotonin transporter genotype in predicting aggression at the transition to adulthood.

Despite consistent evidence that serotonin functioning affects stress reactivity and vulnerability to aggression, research on serotonin gene-stress interactions (G × E) in the development of aggression remains limited. The present study investigated variation in the promoter region of the serotonin transporter gene (5-HTTLPR) as a moderator of the stress-aggression association at the transition to adulthood. Multiple informants and multiple measures were used to assess aggression in a cohort of 381 Australian youth (61% female, 93% Caucasian) interviewed at ages 15 and 20. At age 20, semistructured interviews assessed acute and chronic stressors occurring in the past 12 months. Structural equation modeling analyses revealed a significant main effect of chronic stress, but not 5-HTTLPR or acute stress, on increases in aggression at age 20. Consistent with G × E hypotheses, 5-HTTLPR short allele carriers demonstrated greater increments in aggression following chronic stress relative to long allele homozygotes. The strength of chronic stress G × E did not vary according to sex. Variation at 5-HTTLPR appears to contribute to individual differences in aggressive reactions to chronic stress at the transition to adulthood.

Mediators of aggression among young adult offspring of depressed mothers.

The current article explores the connection between maternal depression and offspring aggression during the transition to adulthood, expanding the scope of prior research on this topic. Both family-level factors (including parent-child relationship quality and maternal romantic relationship quality) and youth factors (including depression history and social functioning in midadolescence) were tested as potential mediators in a longitudinal community sample of 710 youth at ages 15 and 20. The results suggest that maternal depression confers a risk for higher levels of aggressive behavior by offspring at age 20. Structural equation models suggested that the association between maternal depression and youth aggression is fully mediated by youth history of depression by midadolescence, even when accounting for the stability of aggression between ages 15 and 20. Parent-child relationship quality, youth social functioning, and maternal relationship quality were not unique mediators of this association. Limitations and implications are discussed.

Chronic and acute stress, gender, and serotonin transporter gene-environment interactions predicting depression symptoms in youth.

BACKGROUND: Many recent studies of serotonin transporter gene by environment effects predicting depression have used stress assessments with undefined or poor psychometric methods, possibly contributing to wide variation in findings. The present study attempted to distinguish between effects of acute and chronic stress to predict depressive symptoms at age 20 among 346 youth varying in polymorphisms of the 5HTT gene who had been assessed at ages 15 and 20. METHODS: Interview measures assessed major acute life events between 15 and 19, and multiple interviews and questionnaires with youths and their parents at youth age 15 provided an index of chronic family stress. Lg alleles were reclassified as S. RESULTS: Chronic family stress at age 15 predicted higher depression scores at 20 among those with one or two S alleles, and the effects of genetic moderation were significant only for females. Gene-environment interactions with acute stress were nonsignificant. CONCLUSIONS: Careful measurement and separation of the effects of chronic and acute stress, and gender, are encouraged in the study of mechanisms of the stress-depression association.

Patterns of adolescent depression to age 20: the role of maternal depression and youth interpersonal dysfunction.

Considerable research has focused on youth depression, but further information is needed to characterize different patterns of onset and recurrence during adolescence. Four outcome groups by age 20 were defined (early onset-recurrent, early-onset-desisting, later-onset, never depressed) and compared on three variables predictive of youth depression: gender, maternal depression, and interpersonal functioning. Further, it was hypothesized that the association between maternal depression and youth depression between 15 and 20 is mediated by early-onset depression and interpersonal dysfunction by age 15. Eight hundred sixteen community youth selected for depression risk by history (or absence) of maternal depression were interviewed at age 15, and 699 were included in the 5-year follow-up. Controlling for gender, early onset and interpersonal dysfunction mediated the link between maternal depression and late adolescent major depression. Different patterns for males and females were observed. For males maternal depression's effect was mediated by early onset but not interpersonal difficulties, while for females maternal depression's effect was mediated by interpersonal difficulties but not early onset. Maternal depression did not predict first onset of major depression after age 15. The results suggest the need for targeting the impact of maternal depression's gender-specific effects on early youth outcomes, and also highlight the different patterns of major depression in youth and their likely implications for future course of depression.

Early onset recurrent subtype of adolescent depression: clinical and psychosocial correlates.

BACKGROUND: Evaluated trajectories of adolescent depression and their correlates in a longitudinal study of a community sample: early onset (by age 15) with major depression (MDE) recurrence between 15 and 20; early onset with no recurrence; later onset of major depression after age 15 with and without recurrence by 20; and never-depressed. METHODS: Eight-hundred sixteen youth were studied at age 15, and 699 were included at age 20, with diagnostic evaluations and assessments of functioning in major roles. RESULTS: Youth with early onset and recurrent MDE differed from both those with early onset but nonrecurrent MDE and those with later onset-no recurrence in terms of clinical features, adolescent social functioning, and later psychosocial adjustment. The early onset recurrent depressed youth had more severe, chronic, suicidal depressions, greater anxiety comorbidity, worse social functioning at 15, and poorer psychosocial, especially social, outcomes at 20. CONCLUSIONS: Youth with depression by 15 with recurrence by age 20 may represent a high-risk group, with likely life-course-persistent depression and maladjustment. Community youth whose early depression does not recur by age 20, or who have onset with no recurrence after age 15, may have more benign and possibly limited depressions. Later onset with recurrence is also a group at risk for dysfunctional outcomes, requiring further follow-up.

Health outcomes related to early adolescent depression.

PURPOSE: The aim of the present study was to examine whether early adolescent major depressive disorder was associated with negative health outcomes in young adulthood after controlling for depression at the time of follow-up. In addition, indicators of medical and social costs associated with these health consequences were measured. METHODS: A total of 705 adolescents participating in a longitudinal study of children varying in risk for depression due to maternal depression were assessed for a history of depression at age 15 years, depressive disorders at age 20, and a variety of health outcomes at age 20. RESULTS: Results showed that even after controlling for the effects of concurrent depression at age 20, early adolescent depression continued to be associated with poorer interviewer-rated health, poorer self-perceived general health, higher health care utilization and increased work impairment due to physical health, although not with limitations to physical functioning or the presence of chronic medical conditions. CONCLUSIONS: Depression during early adolescence has consequences for health and associated costs during young adulthood. The implications of these findings for screening and treatment of adolescent depression are discussed.

Adolescent psychosocial risk factors for severe intimate partner violence in young adulthood.

The authors examined prospective measures of psychosocial risk factors as predictors of severe intimate partner violence among a community sample of 610 young adults at risk for intergenerational transmission of depression. The hypothesized risk factors were youth history of depression by age 15 and maternal history of depression. Youth social functioning at age 15 was tested as a mediator of these associations. Results showed that youth history of depression by age 15 predicted victimization at age 20. Severe violence perpetration was predicted by maternal depressive history among women but not men. Youth social functioning was a partial mediator of both associations. In sum, the findings suggest that psychosocial factors observed in adolescence may contribute to the risk of experiencing severe intimate partner violence during young adulthood.