Tackling caregiver depression in rural China: A Q&A

After studying early childhood development in China for several years, Alexis Medina, assistant director of Stanford’s Rural Education Action Program (REAP), and her colleagues got a question from a colleague that opened up a whole new line of inquiry. I spoke with Medina recently to learn more:

How did your project on caregiver depression get started?

We have been studying early childhood development in rural China since 2012. We’ve learned that rural babies and toddlers in China lag behind global averages on a number of outcomes, including nutrition, cognition and both language and social-emotional development. Parenting behaviors are also lacking — less than half of rural parents read to, play with or tell stories to their young children. And fewer than 10% of families engage in all three behaviors.

During a seminar in London, an Oxford psychology professor asked us if part of the reason for these low cognition levels and low rates of engagement might be maternal or grandmother depression. We hadn’t considered this before, and felt it was worthy of deeper study.

What did your study find?

We added in a measure of adult depression to our survey forms, and then conducted a large-scale survey of 1,787 caregivers across 118 villages in one northwestern province. When the results (which appear in Frontiers in Psychology) came back, we were shocked. Nearly one-quarter of women caregivers showed signs of depression. As our Oxford friend predicted, depressed caregivers were also significantly more likely to have children with social-emotional delays.

We also found a large generational disparity: under 20% of mothers showed signs of depression, compared with 35% of grandmothers. This was actually the opposite of what we expected going into the study.

In our study, we also conducted a series of in-depth household interviews with 55 of the caregivers to delve deeper into the potential contributing factors associated with depression. We uncovered some interesting trends that we think of as side effects of a rapidly changing society.

For example, we found that depressed grandmothers consistently felt out of place both within their own household and in society at large. These women were brought up in a struggling rural economy to be farmers and farmers’ wives. Many cannot read. They feel like they’re unemployable in the modern economy, and therefore unable to meaningfully contribute to their family. Meanwhile, they’re often saddled with full-time childcare for energetic toddlers whose parents are off in the big cities working skilled jobs. They are tired, they are lonely and they repeatedly told us that they feel ‘worthless.’

How does mental health differ in China?

We know from our research that there is little understanding of mental health among rural families. We found indications of depression among many rural women caring for toddlers, yet less than half of these had even heard of depression. Mental health is highly stigmatized. And there are a lot of misconceptions, such as assuming everyone with a mental health issue will behave in extreme ways: ‘standing naked in freezing water,’ ‘doing stupid things’ or engaging in violence. And treatment is nearly non-existent.

There is relatively more research done on mental health in urban areas of China. This research shows that levels of stress, anxiety and depression are also quite high. Although there are still large misperceptions about the sources of mental health problems and ways of treating these conditions among urban Chinese, their understanding is much better than that of rural Chinese residents.

What are the next steps?

Our next steps will be to explore ways of addressing these high rates of caregiver depression. We’ve built over 100 village-based parenting centers, where caregivers and their children can visit and play together six days a week. By building a sense of community and empowering caregivers, we hope to help alleviate some of the depressive symptoms we’ve observed. One of our graduate students is currently measuring the impact of these centers on caregiver depression.

We’re also working on an intervention that will provide caregivers with monthly, in-home mental health support. We would like to also learn more about any existing resources offered through rural health centers, and see if we can work with local governments to build on existing programs.

On the most fundamental level, there needs to be more awareness of the issues — from both families and health care workers — so that talking about mental health can become less stigmatized.

Photo by Laura Jonsson courtesy of REAP

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Will antidepressants work? Brain activity can help predict

You, or someone you care about, probably take an antidepressant — given that one in eight Americans do. Despite this widespread use, many experts question whether these drugs even work. Studies have shown that antidepressants are only slightly more effective than a placebo for treating depression.

“The interpretation of these studies is that antidepressants don’t work well as medications,” said Stanford psychiatrist and neurobiologist Amit Etkin, MD, PhD. “An alternative explanation is that the drugs work well for a small portion of people, but we’re giving them to too broad of a population and diminishing overall efficacy. Right now, we prescribe antidepressants based on patients’ clinical symptoms rather than an understanding of their biology.”

In a new study, Etkin and his collaborators sought a biologically-based method for predicting whether antidepressants will work for an individual patient.

The researchers analyzed data from the EMBARC study, the first randomized clinical trial for depression with both neuroimaging and a placebo control group. EMBARC included over 300 medication-free depressed outpatients who were randomized to receive either the antidepressant sertraline (brand name Zoloft) or a placebo for eight weeks.

Etkin’s team analyzed functional magnetic resonance imaging (fMRI) data — taken before treatment started — to view the patients’ brain activity while they performed an established emotional-conflict task. The researchers were interested in the brain circuitry that responds to emotion because depression is known to cause various changes in how emotions are processed and regulated.

During the task, the patients were shown pictures of faces and asked to categorize whether each facial expression depicted fear or happiness, while trying to ignore a word written across the face. The distracting word either matched or mismatched the facial expression. For example, the fearful face either had “happy” or “fear” written across it, as shown below.

Participants were asked to decide if this expression was happy or fearful.
(Image courtesy of Amit Etkins)

As expected, having a word that was incongruent with the facial expression slowed down the participants’ response time, but their brains were able to automatically adapt when a mismatch trial was followed by another mismatch trial.

“You experience the mismatched word as less interfering, causing less of a slowdown in your behavior, because your brain has gotten ready for it,” explained Etkin.

However, the participants varied in their ability to adapt. The study found that the people who could adapt well to the mismatched emotional stimuli had increased activity in certain brain regions, but they also had massively decreased activity in other brain regions — particularly in places important for emotional response and attention. In essence, these patients were better able to dampen the distracting effects of the stimuli.

Using machine learning, the researchers determined that they could use this fMRI brain activation signature to successfully predict which individual patients responded well to the antidepressant compared to the placebo.

“The better you’re able to dampen the effects of emotional stimuli on emotional and cognitive centers, the better you respond to an antidepressant medication compared to a placebo,” Etkin said. “This means that we’ve established a neurobiological signature reflective of the kind of person who is responsive to antidepressant treatment.”

This brain activation signature could be used to separate the people for whom a regular antidepressant works well from those who might need something new and more tailored. But it could also be used to assess potential interventions — such as medications, brain stimulation, cognitive training or mindfulness training — to help individuals become treatment responsive to antidepressants, he said.

“I think the most important result is that it turns out that antidepressants are not ineffective. In fact, they are quite effective compared to placebo if you give them to the right people. And we’ve identified who those people are using objective biological measures of brain activity.”

The team is currently investigating in clinics around the country whether they can replace the costly fMRI neuroimaging with electroencephalography, a less expensive and more widely available way to measure brain activity.  

Etkin concluded with a hopeful message for all patients suffering from depression: “Our data echoes the experience that antidepressants really help some people. It’s just a question of who those people are. And our new understanding will hopefully accelerate the development of new medications for the people who don’t respond to an antidepressant compared to placebo because we also understand their biology.”

Feature image by inspiredImages

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Ramadan: Advising clinicians on safe fasting practices

Photo by mohamed_hassan

If you are a basketball fan who recently watched Portland Trail Blazers’ Enes Kanter play against the Warriors in the western NBA semi-finals, you may have heard about Ramadan fasting. But most Americans haven’t — and that includes clinicians.

“Even those clinicians who are aware of Ramadan often do not fully understand the nuances of fasting,” explains Rania Awaad, MD, a clinical assistant professor of psychiatry and behavioral sciences and the director of the Muslims and Mental Health Lab at Stanford. “For example, there is no oral intake from sunup to sundown of food, liquids and also medications. For clinicians who may be alarmed by this, it’s important to remember that fasting is globally practiced safely by adjusting the timing and dosing of medications and by following best practices like consuming enough fluids to rehydrate after the fast.”

Ramadan is the ninth month of the Islamic calendar, which is 11 days shorter than the solar year. This year in the U.S., it began on May 5 and ends on June 4. During Ramadan, many of the nearly two billion Muslims around the world fast during the sunlight hours as a means of expressing self-control, gratitude and compassion for those in need.

Several groups are exempted from this religious requirement — including pregnant women, children, the elderly and people who are acutely or chronically ill — but some fast anyway because of the spiritual significance, Awaad says.

“Ramadan is a very spiritual and communal month. So when clinicians immediately advise their patients not to fast, they may not realize they’re inadvertently isolating their patients from the broader community and support system,” Awaad says. She notes this is particularly important for patients with mental health disorders.

Awaad says she strongly advises clinicians to encourage their patients to seek a dual consultation with both a faith leader and medical professional at places like the Khalil Center, a professional counseling center specializing in Muslim mental health. Alternatively, patients observing Ramadan can consult both their faith leader and physician individually and help facilitate a consultation between both entities.

“Without a holistic treatment plan, patients are either fasting when they shouldn’t be — not taking their medications without telling their health care provider — or they are potentially not partaking in Ramadan when they can be,” Awaad says.

In a recent editorial in The Lancet Psychiatry, Awaad and her colleagues outline more clinical suggestions on the safety and advisability of Ramadan fasting that she hopes physicians will consider. For example, the editorial suggests that physicians working with patients with eating disorders should discuss the risks and benefits of fasting and consider close follow-up in this period and in the months following.

But the first step is knowing whether patients are Muslim. By co-teaching the “Culture and Religion in Psychiatry” class, Awaad says she helps Stanford psychiatry residents become comfortable asking about their patients’ religion, in the same way they are trained to ask other sensitive questions like sexual orientation.

“If we miss that our patient draws strength and support from their religion, then we miss the opportunity to support them holistically by incorporating their faith leader or faith community into their treatment plans,” Awaad explains. “The last Gallop poll revealed 87 percent of Americans believe in God, so it’s important to incorporate this into our patient care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Genetic roots of psychiatric disorders clearer now thanks to improved techniques

Photo by LionFive

New technology and access to large databases are fundamentally changing how researchers investigate the genetic roots of psychiatric disorders.

“In the past, a lot of the conditions that people knew to be genetic were found to have a relatively simple genetic cause. For example, Huntington’s disease is caused by mutations in just one gene,” said Laramie Duncan, PhD, an assistant professor of psychiatry and behavioral sciences at Stanford. “But the situation is entirely different for psychiatric disorders, because there are literally thousands of genetic influences on every psychiatric disorder. That’s been one of the really exciting findings that’s come out of modern genetic studies.”

These findings are possible thanks to genome-wide association studies (GWAS), which test for millions of genetic variations across the genome to identify the genes involved in human disease.

Duncan is the lead author of a recent commentary in Neuropsychopharmacology that explains how GWAS studies have demonstrated the inadequacy of previous methods. The paper also highlights new genetics findings for mental health.

Before the newer technologies and databases were available, scientists could only analyze a handful of genetic variations. So they had to guess that a specific genetic variation (a candidate) was associated with a disorder — based on what was known about the underlying biology — and then test their hypothesis. The body of research that has emerged from GWAS studies, however, show that nearly all of these earlier “candidate study” results are incorrect for psychiatric disorders.

“There are actually so many genetic variations in the genome, it would have been almost impossible for people to guess correctly,” Duncan said. “It was a reasonable thing to do at the time. But we now have better technology that’s just as affordable as the old ways of doing things, so traditional candidate gene studies are no longer needed.”

Duncan said she began questioning the candidate gene studies as a graduate student. As she studied the scientific literature, she noticed a pattern in the data that suggested the results were wrong. “The larger studies tended to have null results and the very small studies tended to have positive results. And the only reason you’d see that pattern is if there was strong publication bias,” said Duncan. “Namely, positive results were published even if the study was small, and null results were only published when the study was very large.”

In contrast, the findings from the GWAS studies become more and more precise as the sample size increases, she explained, which demonstrates their reliability.

Using GWAS, researchers now know that thousands of variations distributed across the genome likely contribute to any given mental disorder. By using the statistical power gleaned from giant databases such as the UK Biobank or the Million Veterans Program, they have learned that most of these variations aren’t even in the regions of the gene’s DNA that code for proteins, where scientists expected them to be. For example, only 1.1 percent of schizophrenia risk variants are in these coding regions.

“What’s so interesting about the modern genetic findings is that they are revealing entirely new clues about the underlying biology of psychiatric disorders,” Duncan said. “And this opens up lots of new avenues for treatment development.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Tips for discussing suicide on social media — A guide for youth

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Photo by kaboompics

There are pros and cons to social media discussions of suicide. Social media can spread helpful knowledge and support, but it can also quickly disseminate harmful messaging and misinformation that puts vulnerable youth at risk.

New U.S. guidelines, called #chatsafe: A Young Person’s Guide for Communicating Safely Online About Suicides, aim to address this problem by offering evidence-based advice on how to constructively interact online about this difficult topic. The guidelines include specific language recommendations.

Vicki Harrison, MSW, the program director for the Stanford Center for Youth Mental Health and Wellbeing, discussed this new online education tool — developed in collaboration with a youth advisory panel — in a recent Healthier, Happy Lives Blog post.

“My hope is that these guidelines will create awareness about the fact that the way people talk about suicide actually matters an awful lot and doing so safely can potentially save lives. Yet we haven’t, up to this point, offered young people a lot of guidance for how to engage in constructive interactions about this difficult topic,” Harrison said in the blog post. “Hopefully, these guidelines will demystify the issue somewhat and offer practical suggestions that youth can easily apply in their daily interactions.”

A few main takeaways from the guidelines are below:

Before you post anything online about suicide

Remember that posts can go viral and they will never be completely erased. If you do post about suicide, carefully choose the language you use. For example, avoid words that describe suicide as criminal, sinful, selfish, brave, romantic or a solution to problems.

Also, monitor the comments for unsafe content like bullying, images or graphic descriptions of suicide methods, suicide pacts or goodbye notes. And include a link to prevention resources, like suicide help centers on social media platforms. From the guidelines:

“Indicate suicide is preventable, help is available, treatment can be successful, and that recovery is possible.”

Sharing your own thoughts, feelings or experience with suicidal behavior online

If you’re experiencing suicidal thoughts or feelings, try to reach out to a trusted adult, friend or professional mental health service before posting online. If you are feeling unsafe, call 911.

In general, think before you post: What do you hope to achieve by sharing your experience? How will sharing make you feel? Who will see your post and how will it affect them?

If you do post, share your experience in a safe and helpful way without graphic references, and consider including a trigger warning at the beginning to warn readers about potentially upsetting content.

Communicating about someone you know who is affected by suicidal thoughts, feelings or behaviors

If you’re concerned about someone, ask permission before posting or sharing content about them if possible. If someone you know has died by suicide, be sensitive to the feelings of their grieving family members and friends who might see your post. Also, avoid posting or sharing posts about celebrity suicides, because too much exposure to the suicide of well-known public figures can lead to copycat suicides.

Responding to someone who may be suicidal

Before you respond to someone who has indicated they may be at risk of suicide, check in with yourself: How are you feeling? Do you understand the role and limitations of the support you can provide?

If you do respond, always respond in private without judgement, assumptions or interruptions. Ask them directly if they are thinking of suicide. Acknowledge their feelings and let them know exactly why you are worried about them. Show that you care. And encourage them to seek professional help.

Memorial websites, pages and closed groups to honor the deceased

Setting up a page or group to remember someone who has died can be a good way to share stories and support, but it also raises concerns about copycat suicides. So make sure the memorial page or group is safe for others — by monitoring comments for harmful or unsafe content, quickly dealing with unsupportive comments and responding personally to participants in distress. Also outline the rules for participation.

Individuals in crisis can receive help from the Santa Clara County Suicide & Crisis Hotline at (855) 278-4204. Help is also available from anywhere in the United States via Crisis Text Line (text HOME to 741741) or the National Suicide Prevention Lifeline at (800) 273-8255. All three services are free, confidential and available 24 hours a day, seven days a week.

This is a resposting of my Scope blog story, courtesy of Stanford School of Medicine.

Can AI improve access to mental health care? Possibly, Stanford psychologist says

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Image by geralt

“Hey Siri, am I depressed?” When I posed this question to my iPhone, Siri’s reply was “I can’t really say, Jennifer.” But someday, software programs like Siri or Alexa may be able to talk to patients about their mental health symptoms to assist human therapists.

To learn more, I spoke with Adam Miner, PsyD, an instructor and co-director of Stanford’s Virtual Reality-Immersive Technology Clinic, who is working to improve conversational AI to recognize and respond to health issues.

What do you do as an AI psychologist?

“AI psychology isn’t a new specialty yet, but I do see it as a growing interdisciplinary need. I work to improve mental health access and quality through safe and effective artificial intelligence. I use methods from social science and computer science to answer questions about AI and vulnerable groups who may benefit or be harmed.”

How did you become interested in this field?

“During my training as a clinical psychologist, I had patients who waited years to tell anyone about their problems for many different reasons. I believe the role of a clinician isn’t to blame people who don’t come into the hospital. Instead, we should look for opportunities to provide care when people are ready and willing to ask for it, even if that is through machines.

I was reading research from different fields like communication and computer science and I was struck by the idea that people may confide intimate feelings to computers and be impacted by how computers respond. I started testing different digital assistants, like Siri, to see how they responded to sensitive health questions. The potential for good outcomes — as well as bad — quickly came into focus.”

Why is technology needed to assess the mental health of patients?

“We have a mental health crisis and existing barriers to care — like social stigma, cost and treatment access. Technology, specifically AI, has been called on to help. The big hope is that AI-based systems, unlike human clinicians, would never get tired, be available wherever and whenever the patient needs and know more than any human could ever know.

However, we need to avoid inflated expectations. There are real risks around privacy, ineffective care and worsening disparities for vulnerable populations. There’s a lot of excitement, but also a gap in knowledge. We don’t yet fully understand all the complexities of human–AI interactions.

People may not feel judged when they talk to a machine the same way they do when they talk to a human — the conversation may feel more private. But it may in fact be more public because information could be shared in unexpected ways or with unintended parties, such as advertisers or insurance companies.”

What are you hoping to accomplish with AI?

“If successful, AI could help improve access in three key ways. First, it could reach people who aren’t accessing traditional, clinic-based care for financial, geographic or other reasons like social anxiety. Second, it could help create a ‘learning healthcare system’ in which patient data is used to improve evidence-based care and clinician training.

Lastly, I have an ethical duty to practice culturally sensitive care as a licensed clinical psychologist. But a patient might use a word to describe anxiety that I don’t know and I might miss the symptom. AI, if designed well, could recognize cultural idioms of distress or speak multiple languages better than I ever will. But AI isn’t magic. We’ll need to thoughtfully design and train AI to do well with different genders, ethnicities, races and ages to prevent further marginalizing vulnerable groups.

If AI could help with diagnostic assessments, it might allow people to access care who otherwise wouldn’t. This may help avoid downstream health emergencies like suicide.”

How long until AI is used in the clinic?

“I hesitate to give any timeline, as AI can mean so many different things. But a few key challenges need to be addressed before wide deployment, including the privacy issues, the impact of AI-mediated communications on clinician-patient relationships and the inclusion of cultural respect.

The clinician–patient relationship is often overlooked when imagining a future with AI. We know from research that people can feel an emotional connection to health-focused conversational AI. What we don’t know is whether this will strengthen or weaken the patient-clinician relationship, which is central to both patient care and a clinician’s sense of self. If patients lose trust in mental health providers, it will cause real and lasting harm.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Myths and facts: Stanford psychiatrist discusses schizophrenia

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Image by geralt

Inaccurate stereotypes and erroneous beliefs abound concerning schizophrenia. Stanford psychiatrist Jacob Ballon, MD, dispelled a few of these myths in a recent article in Everyday Health. Here are the takeaways and a bit of basic info regarding the disease:

  • There is an underlying, complex genetic component to schizophrenia that is not understood well enough to provide a diagnosis or guide treatment. Ballon said about 10 percent of the disease risk can be attributed to genetics.
  • Schizophrenics do not have multiple personalities — that is called dissociative identity disorder.
  • Most cases of schizophrenia develop between adolescence and age 30; children rarely develop schizophrenia.
  • People with schizophrenia as a group are not more prone to violent behavior. Although there is an association between violence and schizophrenia, the additional risk is largely due to substance abuse.
  • People with schizophrenia have a significantly higher risk of suicide and depression.
  • People with schizophrenia can have delusions and hallucinations. A delusion is a belief and a hallucination is a sensory experience, like a vision. Delusions can include persecutory delusions of feeling watched or followed, thoughts of feeling contaminated or delusions of grandeur. If you are with someone with schizophrenia, keep in mind that the delusion or hallucination is very real to them.
  • Movement can be affected and people with schizophrenia may have difficulty speaking or struggling to pay attention or remember things. Their decision-making may also be compromised.
  • Although there is no cure for schizophrenia, there are effective treatments, including psychotherapy and medications.
  • Starting treatment soon after the disease develops is thought to be the most beneficial.

“There are a number of people who are treated for schizophrenia and are doing quite well,” said Ballon in the article. He added, “If people are able to participate in psychotherapy, they can better extend the value of the medication and also apply some helpful principles to actual experiences in their life. I want people to get help and support with school and employment because I believe they’ll be able to get back on an upward trajectory much more quickly if they get help at an early stage.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.