Review Explores Role of Orbitofrontal Cortex in Depression

The orbitofrontal cortex (OFC)—a region of the brain involved in processing emotions and reward—plays a key role in major depressive disorder, wrote the authors of a review article in Molecular Psychiatry. They describe evidence supporting the different ways that dysfunction in the OFC contributes to major depression and how conventional antidepressants only mitigate some of these problems.

“Despite strong evidence for anatomic and functional heterogeneity within the OFC, some studies have treated this region as a unified whole,” wrote Bei Zhang, M.D., of Fudan University in China and colleagues. “Our proposal, which distinguishes between the medial and lateral OFC in a reward and non-reward/punishment framework, describes functional differentiation within the OFC, and importantly, proposes how this differentiation is associated with different symptoms of [major depressive disorder].”

The authors reviewed numerous neuroimaging studies comparing the brain structure and brain activity of people with or without depression. They reported that people with major depression have reduced connectivity between the medial OFC (the middle segment of the region) and other brain regions that are involved in emotional learning, such as the amygdala. Zhang and colleagues suggested that lower connectivity between these regions may reduce individuals’ sensitivity to positive rewards, leading to greater anhedonia (inability to experience pleasure). In contrast, people with major depression tend to have increased connectivity between the lateral OFC (left and ride sides) and regions that regulate attention and decision making, such as the anterior cingulate cortex. Zhang and colleagues suggested that higher connectivity between these regions may increase individuals’ sensitivity to aversive stimuli, leading to negative bias (the tendency to dwell on negative events).

Zhang and colleagues described other studies that show that antidepressants such as selective serotonin reuptake inhibitors mainly restore normal connectivity in the lateral OFC but have minimal impact on the medial OFC. However, emerging data suggest that ketamine—which targets glutamate rather than serotonin—may boost connectivity in the medial OFC and may be a more promising option when anhedonia is a primary symptom. Psychedelics may also improve connectivity to and from the medial OFC, though to date, only one study has demonstrated this.

“[A]lthough we have underscored the critical role of the OFC in depression, it is unlikely that depression can be solely attributed to impairments in a single brain region due to its complexity and heterogeneity,” the authors concluded. “More evidence is needed to examine how these other brain regions interact with the orbitofrontal cortex in MDD or different subtypes of MDD.”

To read more on this topic, see The American Journal of Psychiatry review, “Toward a Better Understanding of the Mechanisms and Pathophysiology of Anhedonia: Are We Ready for Translation?”

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Look for Your 2024 APA Election Ballot!

All voting members should have received their electronic ballot for APA’s 2024 election by now. If you haven’t seen yours yet, take a moment to look for it in your email inbox and vote. You can also vote on the APA election website by entering your APA username and password. Detailed information about the candidates and campaigning guidelines can also be accessed on the site. Help shape the future of APA by casting your ballot today.

Childhood Cancer Survivors Have Greater Risk of Some Mental Disorders in Adulthood

Children, adolescents, and young adults who survive cancer may be more likely to experience depression, anxiety, and psychotic disorders such as schizophrenia after cancer remission compared with their peers and siblings who did not have cancer, according to a study published today in JAMA Pediatrics.

“It is well established that a diagnosis of cancer and subsequent treatment may be highly traumatizing for all age groups, especially for children in their formative years,” wrote Ainsley Ryan Yan Bin Lee, M.B.B.S., of the Yong Loo Lin School of Medicine at the National University of Singapore and colleagues. “Detecting those [children, adolescents, and young adults with cancer] at a higher risk for prolonged distress by studying the risk and risk factors is crucial to facilitate appropriate and timely psychological interventions.”

Lee and colleagues conducted a systematic review of studies published from 2000 to 2022 in PubMed, MEDLINE, Embase, PsycINFO, CINAHL, and PubMed Central. The studies measured risk and/or severity of depression, anxiety, psychotic disorders, and death by suicide in children, adolescents, and young adults with cancer compared with those who did not have cancer, which could include family members or matched controls. The studies included both patients currently receiving treatment for cancer and cancer survivors. Those actively receiving cancer treatment were no older than 25 years, and those who were cancer survivors received their cancer diagnoses when they were no older than 25 years.

The authors analyzed 52 studies. Youth with cancer had a significantly increased lifetime risk of severe depression symptoms, anxiety, and psychotic disorders compared with both family members and matched controls. Additional findings include the following:

• The risk of severe depression or anxiety symptoms was elevated regardless of the participant’s age at cancer diagnosis.
• Depression severity was elevated in both youth receiving active cancer treatment and cancer survivors.
• Anxiety severity was elevated in youth receiving active cancer treatment, but not in cancer survivors.
• Certain subpopulations of youth with cancer or a history of cancer had a significantly increased risk of suicide mortality, particularly those diagnosed between the ages of 15 and 19 years.
• Several studies found significant associations between lower educational levels and increased risk of mental illness or suicide; lower income and increased risk of depression, anxiety, or both; and partnership status and lower risk of depression and anxiety.

The authors concluded by urging policymakers and health care professionals to be cognizant of vulnerable subgroups who may develop severe psychiatric illnesses following a cancer diagnosis.

“The results of this study offer the interprofessional [children, adolescent, and young adult] oncology community an opportunity: we can put the debate about survivors’ mental health risks to rest,” wrote Abby Rosenberg, M.D., M.S., M.A., and Anna Muriel, M.D., M.P.H., of the Dana-Farber Cancer Institute in Boston in an accompanying commentary. “We can accept that these patients are more likely to suffer from clinically significant depression, anxiety, [and] psychotic disorders, and—in some cases—are at higher risk of death by suicide. We can therefore devote our energies to determining how to meet the needs of each patient in real time, targeting those most at risk.”

For related information, see the Psychiatric News article “Expert’s Corner: Best Practices for Treating Cancer Patients With Psychiatric Symptoms” and the Psychiatric Services article “Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer.

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Psychiatric News Invites Applications for
Medical Editor-in-Chief

APA members who have administrative experience, are passionate about disseminating news in the field of psychiatry, and are knowledgeable about print and digital communications are invited to apply. The deadline for applications, which should include a vision statement and a curriculum vitae, is July 19, 2023.

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Migraine in Young People Linked to Anxiety, Depressive Disorders, Study Shows

Children and adolescents with migraine have approximately twice the risk of anxiety or depression compared with youth without migraine, according to a report in the December JAMA Pediatrics.

“One in 10 children and adolescents experience migraine and, across the life span, it is the second most prevalent and disabling disease worldwide,” wrote Katherine Falla, M.D., of the University of Calgary and colleagues. “These results have critical implications for clinical practice, underscoring the need to screen all children and adolescents with migraine for anxiety and depression.”

The researchers searched the medical literature for case-control, cohort, and cross-sectional studies assessing the association between internalizing symptoms and/or disorders (such as anxiety and depression) and migraine in children and adolescents aged 18 years or younger. Eighty studies were included in the final analysis.

The researchers found that children with migraine had double the odds of having anxiety and depressive disorders compared with healthy controls. Moreover, in studies that pooled results for anxiety and depressive disorders, young people with migraine were more than four times as likely to have mixed anxiety and/or depressive disorders, according Falla and colleagues.

In an accompanying editorial, Jessica Hauser Chatterjee, M.D., Ph.D., and Heidi K. Blume, M.D., M.P.H., of the University of Washington School of Medicine noted that combination treatment with fluoxetine and cognitive-behavioral therapy (CBT) is one of the best approaches to the treatment of children with depressive disorders, and that CBT for migraine is one of the most successful treatments for youth with chronic migraine. They added that some youth with headache disorders may need treatment for other psychiatric disorders.

“The work by Falla and colleagues provides strong support for the expansion and increased availability [of] multifaceted and interdisciplinary approaches to migraine treatment,” they wrote.

For related information, see the Psychiatric News article “Psychiatrists Have Role in Managing Pediatric Pain.”

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Live Meet-the-Candidate Town Halls End Tomorrow

Tomorrow marks the final day for APA’s live, virtual meet-the-candidate town halls, but recordings of the town halls held this week will soon be available. The Thursday town hall will feature candidates for resident-fellow member trustee-elect (elected by RFMs only). The town hall will begin at noon ET and run 30 to 60 minutes. Also, check out the bios and brief videos of all the candidates and read APA’s 2023 Election Guide to the Candidates. Voting begins Tuesday, January 3.

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Many Parents Screen Positive for Depressive Symptoms After Postpartum Period, Study Finds

More than a quarter of parents with children over age 1 may show signs of depression, according to a report published this week in Pediatrics. The findings suggest that screening for parental depression beyond the immediate postpartum period has the potential to identify families in need of support.

“Early recognition and treatment of parental depression can mitigate negative effects on child health and development,” wrote Ava Marie Hunt, M.D., of the Children’s Hospital of Philadelphia and colleagues. Currently, the American Academy of Pediatrics recommends that pediatric clinicians screen for maternal depression during the initial postpartum period (the first year of life), the authors continued.

Hunt and colleagues searched PubMed, CINAHL, SCOPUS, Web of Science, and APA PsycInfo for studies concerning screening for maternal and/or paternal depression or mood disorders by a pediatric clinician when children were older than age 1.

The authors identified 41 studies, including more than 32,700 parents and caregivers, 68% of which included only mothers. An average of 25.5% of participants in the studies screened positive for depressive symptoms, with the highest reported proportion among mothers of patients with cystic fibrosis. Single motherhood and parental educational attainment less than a high school degree were associated with increased risk of depressive symptoms. Additionally, parental depression was associated with an increased risk of both child behavioral and physical health outcomes, including anxiety, depression, and malnutrition. It was also associated with parents’ negative views of child behavior. Four of the studies examined the acceptability of the parental depression screenings, and all found that screenings were acceptable to clinicians and/or parents/other caregivers.

The authors identified numerous gaps in the existing literature, including that structured screening programs outside of the postpartum period in pediatric settings were rare, especially for fathers. They also found that appropriate referral and follow-up of positive screens posed a major challenge in the studies.

“[T]he current literature clearly documents the high number of parents who screen positive outside of the immediate postpartum period as well as its impact on the well-being of parents and children,” the authors concluded. “The findings also suggest that additional research is required to assess the best practices for referral and follow-up of parents who screen positive for depressive symptoms to ensure they receive the support they need.”

For related information, see the Psychiatric News article “Postpartum Anxiety, Depression Raise Risk of Developmental Delays.”

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APA Journal Pilots Race, Ethnicity, and Culture Checklist for Submissions, Review of MH Research

“Structural racism … has a long history in medical journals, and Psychiatric Services is no exception,” wrote Psychiatric Services Editor Lisa Dixon, M.D., M.P.H., and colleagues in an editorial published today in the journal. It “affects who runs the journal, who submits and reviews, what topics are emphasized, how the role of racism and ethnoracial categories are conceptualized and included or ignored in analyses and discussions, and what policy and services recommendations are made.”

Since 2020, Psychiatric Services has taken steps to examine the effects of structural racism on the journal and institute changes to address it, including enhancing the diversity of the editorial board and column editors; appointing a 12-member antiracism task force to advise the journal; publishing peer-reviewed articles and commentaries that address racism; and more. Psychiatric Services will now “embark on the next phase of this process, which directly involves the submission and peer-review procedures,” Dixon and colleagues wrote.

As part of a six-month pilot, authors submitting research articles to the journal will be prompted to use a 16-item checklist during the submission process to assess the comprehensiveness and applicability of factors related to race/racialization, ethnicity, and culture (REC) in their mental health research articles. (The checklist that Psychiatric Services will use is a modified version of an REC checklist developed by the Cultural Committee of the Group for the Advancement of Psychiatry, under the leadership of Roberto Lewis-Fernández, M.D., a professor of clinical psychiatry at Columbia University.)

The journal editors will seek feedback from authors and reviewers about the use of the checklist. “Our accumulated experience will be used to guide ongoing use of the checklist and possible expansion to other types of articles. Our experience may also serve as a guide for other journals interested in the use of the checklist,” Dixon and colleagues wrote.

They concluded, “Our aim as a journal is to engage in a continuous process of reevaluation and improvement to produce a corpus of high-quality published work that contributes to the ongoing process of promoting health equity and eliminating the impact of structural racism in mental health services. Implementing the REC Checklist is one more step in this process. We welcome your input and suggestions for additional ways to achieve our goal; comments may be directed to PSCentral@psych.org (subject line: REC Checklist).”

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Did You Fail to File Report on Provider Relief Funds You Received?

The Health Resources and Services Administration has announced that health care providers who received funds from the Provider Relief Fund program and did not submit their Reporting Period 1 report by the deadline may request to submit a late report, via a DocuSign form, if certain extenuating circumstances exist. The requests must be filed from Monday, April 11, to Friday, April 22, at 11:59 p.m. ET and must attest to a clear, concise explanation regarding the extenuating circumstance; no supporting documentation is required. Those whose request is approved will be notified to complete the Reporting Period 1 report within 10 days. Providers will also have an opportunity to submit a Request to Report Late Due to Extenuating Circumstances for Reporting Period 2. Notification regarding the process to submit the request will be announced in the coming weeks. For more information, call the Provider Support Line at (866) 569-3522; for TTY dial 711. Hours of operation are weekdays from 8 a.m. to 10 p.m. Central Time.

Use of Consultation-Liaison Psychiatry May Reduce Hospital Patients’ Length of Stay

The use of proactive consultation-liaison psychiatry, along with clinically informed screening and integrated mental health care delivery, appears to help reduce patients’ average length of stay in the hospital, according a report in General Hospital Psychiatry.

“The unmet need for psychiatric care in the general hospital is substantial and compromises the quality and delivery of care,” wrote Mark Oldham, M.D., of the University of Rochester Medical Center and colleagues. “Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.”

Researchers systematically reviewed studies from Pubmed, Embase, PsycINFO, and Cochrane Library published through May 2019, seeking studies that examined how early mental health screening of hospitalized adults impacted patients’ length of stay. Though initially yielding 738 results, only 12 studies were included in the systematic review after researchers “evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.”

The studies used various screening and intervention methods for patients. In some, psychiatrists met with all patients in a given setting, such as after hip fracture surgery, while in others, patients were identified using standardized instruments as needing mental health care. In most studies, the intervention “was a formal psychiatric consultation by services variously staffed by psychiatrist, trainees, nurses, and research personnel.”

Most of the studies reported reduced length of stay for patients; two studies also reported “favorable returns on investment that more than offset the increased costs of providing this level of enhanced care,” Oldham and colleagues wrote. While the authors noted that “the heterogeneity across study designs makes it difficult to attribute this to any one study element in isolation,” they added that three interrelated elements of each of the studies appear to be tied to positive outcomes: “screening that draws upon mental health care expertise, integrated care delivery, and unit- or service-level analysis.”

“All studies investigating models wherein care delivery was integrated with primary services—either as embedded psychiatrists or multidisciplinary team-based care—reported either a statistical reduction in LOS [length of stay] or a trend in favor of reduced LOS,” they wrote.

For more information, see the Psychiatric News article “The Role of C-L Psychiatrists in Caring for Cardiac Patients.”

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Integrated Care Model Found to Reduce Racial/Ethnic Disparities in Mental Health Care

Interventions that used a model of integrated care reduced the disparity between racial/ethnic minorities and whites obtaining mental health care for the first time, according to a review published yesterday in Psychiatric Services in Advance.

Between 2004 and 2012, the gulf between whites and racial/ethnic groups in accessing mental health care widened in the United States, wrote Su Yeon Lee-Tauler, Ph.D., of the Uniformed Services University of the Health Sciences and Johns Hopkins University Bloomberg School of Public Health and colleagues.

Their systematic review drew from three databases in February 2016 and examined interventions intended to improve initiation of mental health services among racial/ethnic minority groups. A total of 29 studies were examined.

“[S]even studies provided evidence that screening and referral, colocation of primary care and mental health services, and collaborative care interventions not only improved mental health outcomes but also contributed to disparities reduction in initiation of care,” Lee-Tauler and colleagues wrote. “Notably, six of the seven interventions that reduced racial/ethnic disparities in initiation of mental health services primarily used an integrated care model. Each of the six interventions resulted in increased uptake of psychotherapy or antidepressant use among members of racial/ethnic minority groups compared with white participants.”

Of the 29 studies examined, 23 incorporated adaptations (either social, cultural, or linguistic) designed to address barriers to care. These adaptations involved incorporating feedback from participants from racial/ethnic minority groups on intervention design, using images and phrases that fit participants’ cultural context, training providers in cultural sensitivity, and providing the interventions bilingually.

“We found evidence that integrated care models hold promise in reducing [racial/ethnic] disparities,” the authors concluded. “Importantly, effective interventions to reduce disparities in care must be widely disseminated and implemented to be of value.”

For related information, see the Psychiatric News article “AAGP Session to Focus on Evaluation, Treatment of Older Minority Patients.”

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