Publications by authors named "Ezra Susser"

273 Publications

Maternal mid-gestational and child cord blood immune signatures are strongly associated with offspring risk of ASD.

Mol Psychiatry 2022 Jan 5. Epub 2022 Jan 5.

Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA.

Epidemiological studies and work in animal models indicate that immune activation may be a risk factor for autism spectrum disorders (ASDs). We measured levels of 60 cytokines and growth factors in 869 maternal mid-gestational (MMG) and 807 child cord blood (CB) plasma samples from 457 ASD (385 boys, 72 girls) and 497 control children (418 boys, 79 girls) from the Norwegian Autism Birth Cohort. We analyzed associations first using sex-stratified unadjusted and adjusted logistic regression models, and then employed machine learning strategies (LASSO + interactions, Random Forests, XGBoost classifiers) with cross-validation and randomly sampled test set evaluation to assess the utility of immune signatures as ASD biomarkers. We found prominent case-control differences in both boys and girls with alterations in a wide range of analytes in MMG and CB plasma including but not limited to IL1RA, TNFα, Serpin E1, VCAM1, VEGFD, EGF, CSF1, and CSF2. MMG findings were most striking, with particularly strong effect sizes in girls. Models did not change appreciably upon adjustment for maternal conditions, medication use, or emotional distress ratings. Findings were corroborated using machine learning approaches, with area under the receiver operating characteristic curve values in the test sets ranging from 0.771 to 0.965. Our results are consistent with gestational immunopathology in ASD, may provide insights into sex-specific differences, and have the potential to lead to biomarkers for early diagnosis.
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http://dx.doi.org/10.1038/s41380-021-01415-4DOI Listing
January 2022

A useful construct to improve the lives of people with schizophrenia.

Schizophr Res 2021 Dec 27. Epub 2021 Dec 27.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States; New York State Psychiatric Institute, New York, NY, United States. Electronic address:

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http://dx.doi.org/10.1016/j.schres.2021.12.010DOI Listing
December 2021

Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial.

Lancet Psychiatry 2022 01;9(1):59-71

Department of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: There have been no trials of task-shared care (TSC) using WHO's mental health Gap Action Programme for people with severe mental disorders (psychosis or affective disorder) in low-income or middle-income countries. We aimed to evaluate the efficacy and cost-effectiveness of TSC compared with enhanced specialist mental health care in rural Ethiopia.

Methods: In this single-blind, phase 3, randomised, controlled, non-inferiority trial, participants had a confirmed diagnosis of a severe mental disorder, recruited from either the community or a local outpatient psychiatric clinic. The intervention was TSC, delivered by supervised, non-physician primary health care workers trained in the mental health Gap Action Programme and working with community health workers. The active comparison group was outpatient psychiatric nurse care augmented with community lay workers (PSY). Our primary endpoint was whether TSC would be non-inferior to PSY at 12 months for the primary outcome of clinical symptom severity using the Brief Psychiatric Rating Scale, Expanded version (BPRS-E; non-inferiority margin of 6 points). Randomisation was stratified by health facility using random permuted blocks. Independent clinicians allocated groups using sealed envelopes with concealment and outcome assessors and investigators were masked. We analysed the primary outcome in the modified intention-to-treat group and safety in the per-protocol group. This trial is registered with ClinicalTrials.gov, number NCT02308956.

Findings: We recruited participants between March 13, 2015 and May 21, 2016. We randomly assigned 329 participants (111 female and 218 male) who were aged 25-72 years and were predominantly of Gurage (198 [60%]), Silte (58 [18%]), and Mareko (53 [16%]) ethnicity. Five participants were found to be ineligible after randomisation, giving a modified intention-to-treat sample of 324. Of these, 12-month assessments were completed in 155 (98%) of 158 in the TSC group and in 158 (95%) of 166 in the PSY group. For the primary outcome, there was no evidence of inferiority of TSC compared with PSY. The mean BPRS-E score was 27·7 (SD 4·7) for TSC and 27·8 (SD 4·6) for PSY, with an adjusted mean difference of 0·06 (90% CI -0·80 to 0·89). Per-protocol analyses (n=291) were similar. There were 47 serious adverse events (18 in the TSC group, 29 in the PSY group), affecting 28 participants. These included 17 episodes of perpetrated violence and seven episodes of violent victimisation leading to injury, ten suicide attempts, six hospital admissions for physical health conditions, four psychiatric admissions, and three deaths (one in the TSC group, two in the PSY group). The incremental cost-effectiveness ratio for TSC indicated lower cost of -US$299·82 (95% CI -454·95 to -144·69) per unit increase in BPRS-E scores from a health care sector perspective at 12 months.

Interpretation: WHO's mental health Gap Action Programme for people with severe mental disorders is as cost-effective as existing specialist models of care and can be implemented effectively and safely by supervised non-specialists in resource-poor settings.

Funding: US National Institute of Mental Health.
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http://dx.doi.org/10.1016/S2215-0366(21)00384-9DOI Listing
January 2022

Hopelessness in New York State Physicians During the First Wave of the COVID-19 Outbreak.

J Neurosurg Anesthesiol 2022 Jan;34(1):152-157

Departments of Anesthesiology.

Background: In the United States, New York State's health care system experienced unprecedented stress as an early epicenter of the coronavirus disease 2019 (COVID-19) pandemic. This study aims to assess the level of hopelessness in New York State physicians working on the frontlines during the first wave of the COVID-19 outbreak.

Methods: A confidential online survey sent to New York State health care workers by the state health commissioner's office was used to gather demographic and hopelessness data as captured by a brief Hopelessness Scale. Adjusted linear regression models were used to assess the associations of physician age, sex, and number of triage decisions made, with level of hopelessness.

Results: In total, 1330 physicians were included, of whom 684 were male (51.4%). Their average age was 52.4 years (SD=12.7), with the majority of respondents aged 50 years and older (55.2%). Almost half of the physician respondents (46.3%) worked directly with COVID-19 patients, and 163 (12.3%) were involved in COVID-19-related triage decisions. On adjusted analysis, physicians aged 40 to 49 years had significantly higher levels of hopelessness compared with those aged 50 years or more (μ=0.441, SD=0.152, P=0.004). Those involved in 1 to 5 COVID-19-related triage decisions had a significantly lower mean hopelessness score (μ=-0.572, SD=0.208, P=0.006) compared with physicians involved in none of these decisions.

Conclusion: Self-reported hopelessness was significantly higher among physicians aged 40 to 49 years and those who had not yet been involved in a life or death triage decision. Further work is needed to identify strategies to support physicians at high risk for adverse mental health outcomes during public health emergencies such as the COVID-19 pandemic.
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http://dx.doi.org/10.1097/ANA.0000000000000808DOI Listing
January 2022

The COVID-19 Healthcare Personnel Study (CHPS): Overview, Methods, and Preliminary Findings.

J Neurosurg Anesthesiol 2022 Jan;34(1):148-151

Department of Anesthesiology, Columbia University Medical Center, New York, NY.

Introduction: The COVID-19 Healthcare Personnel Study (CHPS) was designed to assess adverse short-term and long-term physical and mental health impacts of the coronavirus disease-2019 (COVID-19) pandemic on New York's physicians, nurse practitioners, and physician assistants.

Methods: Online population-based survey. Survey-weighted descriptive results, frequencies, proportions, and means, with 95% confidence intervals (95% CI). Odds ratios (ORs) for association.

Results: Over half (51.5%; 95% CI: 49.1, 54.0) of respondents worked directly with COVID-19 patients; 27.3% (95% CI: 22.5, 32.2) tested positive. The majority (57.6%; 95% CI: 55.2, 60.0) reported a negative impact on their mental health. Negative mental health was associated with COVID-19 symptoms (OR=1.7, 95% CI: 1.3, 2.1) and redeployment to unfamiliar functions (OR=1.3, 95% CI: 1.1, 1.6).

Conclusions: A majority of New York health care providers treated COVID-19 patients and reported a negative impact on their mental health.
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http://dx.doi.org/10.1097/ANA.0000000000000813DOI Listing
January 2022

Response to: "Theory and empiricism: A comment on 'Interrogating the environmental affordances model' by Pamplin and colleagues".

Soc Sci Med 2021 10 10;287:114368. Epub 2021 Sep 10.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

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http://dx.doi.org/10.1016/j.socscimed.2021.114368DOI Listing
October 2021

Response to: "Theory and empiricism: A comment on 'Interrogating the environmental affordances model' by Pamplin and colleagues".

Soc Sci Med 2021 10 10;287:114368. Epub 2021 Sep 10.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

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http://dx.doi.org/10.1016/j.socscimed.2021.114368DOI Listing
October 2021

Examining Power Relations to Understand and Address Social Determinants of Vaccine Uptake.

JAMA Psychiatry 2021 12;78(12):1303-1304

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.

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http://dx.doi.org/10.1001/jamapsychiatry.2021.2497DOI Listing
December 2021

Effectiveness of a Video-Based Intervention on Reducing Perceptions of Fear, Loneliness, and Public Stigma Related to COVID-19: A Randomized Controlled Trial.

Int J Public Health 2021 17;66:1604164. Epub 2021 Aug 17.

New York State Psychiatric Institute (NYSPI), New York, NY, United States.

During the first peak of the COVID-19 outbreak in the United States, we investigated the impact of digital interventions to reduce COVID-19 related fear, loneliness, and public stigma. We recruited and randomly assigned 988 United States residents to: 1) no intervention 2) informational sheet to learn about COVID-19, 3) (2) AND video encouraging digital social activity, 4) (2) AND video sensitizing to COVID-19 related stigma (registered in Clinicaltrials.gov). Surveys were conducted between April 2-16, 2020. We employed generalized linear mixed models to investigate intervention effects. 10% of the participants reported not being afraid of people COVID-19+ and 32% reported not feeling lonely. Stigma and fear items reflected acute worries about the outbreak. Relative to the informational sheet only group, video groups led to greater reduction in perceptions of fear towards COVID-19+ (ORvideo.solo = 0.78, p-val<0.001; ORvideo.friend = 0.79, p-val<0.001) and of stigma (BETAvideo.solo = -0.50, p-val<0.001; BETAvideo.friend = -0.69, p-val<0.001). Video-based interventions lead to reductions in COVID-19-related fear and stigma. No difference in social activity among groups was found, potentially explaining lack of efficacy on loneliness.
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http://dx.doi.org/10.3389/ijph.2021.1604164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407346PMC
September 2021

Short Telomeres and a T-Cell Shortfall in COVID-19: The Aging Effect.

medRxiv 2021 Jul 10. Epub 2021 Jul 10.

The slow pace of global vaccination and the rapid emergence of SARS-CoV-2 variants suggest recurrent waves of COVID-19 in coming years. Therefore, understanding why deaths from COVID-19 are highly concentrated among older adults is essential for global health. Severe COVID-19 T-cell lymphopenia is more common among older adults, and it entails poor prognosis. Much about the primary etiology of this form of lymphopenia remains unknown, but regardless of its causes, offsetting the decline in T-cell count during SARS-CoV-2 infection demands fast and massive T-cell clonal expansion, which is telomere length (TL)-dependent. We have built a model that captures the effect of age-dependent TL shortening in hematopoietic cells and its effect on T-cell clonal expansion capacity. The model shows that an individual with average hematopoietic cell TL (HCTL) at age twenty years maintains maximal T-cell clonal expansion capacity until the 6th decade of life when this capacity plummets by more than 90% over the next ten years. The collapse coincides with the steep increase in COVID-19 mortality with age. HCTL metrics may thus explain the vulnerability of older adults to COVID-19. That said, the wide inter-individual variation in HCTL across the general population means that some younger adults with inherently short HCTL might be at risk of severe COVID-19 lymphopenia and mortality from the disease.

Significance Statement: Declining immunity with advancing age is a general explanation for the increased mortality from COVID-19 among older adults. This mortality far exceeds that from viral illnesses such as the seasonal influenza, and it thus requires specific explanations. One of these might be diminished ability with age to offset the development of severe T-cell lymphopenia (a low T-cell count in the blood) that often complicates COVID-19. We constructed a model showing that age-dependent shortening of telomeres might constrain the ability of T-cells of some older COVID-19 patients to undertake the massive proliferation required to clear the virus that causes the infection. The model predicts that individuals with short telomeres, principally seniors, might be at a higher risk of death from COVID-19.
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http://dx.doi.org/10.1101/2021.05.19.21257474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282112PMC
July 2021

Adaptation and validation of a computerized neurocognitive battery in the Xhosa of South Africa.

Neuropsychology 2021 Sep 5;35(6):581-594. Epub 2021 Jul 5.

Department of Epidemiology, Mailman School of Public Health, Columbia University.

Objective: Large-scale studies have revolutionized biomedical research, and neurocognitive tests can help elucidate the biological basis of neuropsychiatric diseases. However, studies have predominantly been conducted in Western settings. We describe the development and validation of a computerized battery (PennCNB) with the Xhosa population of South Africa.

Method: Individuals with schizophrenia (n = 525) and a normative comparison group (n = 744) were balanced on age, sex, education, and region. Participants provided blood samples, were assessed psychiatrically, and were administered a PennCNB translation to isiXhosa, including measures of executive functions, episodic memory, complex cognition, social cognition, and sensorimotor speed. Feasibility was examined with test completion rates and input from administrators, and psychometric structural validity and associations with clinical and demographic characteristics were examined.

Results: Tests were well tolerated by participants, as >87% had one (or fewer) test missing. Results suggested a similar factor structure to prior PennCNB studies in Western contexts, and expected age and sex effects were apparent. Furthermore, a similar profile of schizophrenia was observed, with neurocognitive deficits most pronounced for executive functions, especially attention, as well as memory, social cognition, and motor speed relative to complex cognition and sensorimotor speed.

Conclusions: Results support the feasibility of implementing a culturally adapted computerized neurocognitive battery in sub-Saharan African settings and provide evidence supporting the concurrent validity of the translated instrument. Thus, the PennCNB is implementable on a large scale in non-Western contexts, shows expected factor structure, and can detect cognitive deficits associated with neuropsychiatric disorders. Obtaining valid measures of cognition by nonspecialized proctors is especially suitable in resource-limited settings, where traditional testing is prohibitive. Future work should establish normative standards, test-retest reliability, and sensitivity to treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/neu0000742DOI Listing
September 2021

Implementation of a pilot community-based psychosocial intervention for patients with psychoses in Chile and Brazil: a comparative analysis of users' perspectives.

Glob Ment Health (Camb) 2021 27;8:e15. Epub 2021 Apr 27.

Mailman School of Public Health, Columbia University, New York, NY, USA.

Background: Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations - incorporating a task-shifting approach and modifying the mode of community-based service delivery - are examined from users' perspectives.

Methods: A secondary analysis of in-depth interviews with CTI-TS users ( = 9 in Brazil; = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS.

Results: Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil.

Conclusion: CTI-TS' major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.
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http://dx.doi.org/10.1017/gmh.2021.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157814PMC
April 2021

Factors Related to Self-Reported Distress Experienced by Physicians During Their First COVID-19 Triage Decisions.

Disaster Med Public Health Prep 2021 Jun 7:1-8. Epub 2021 Jun 7.

Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.

Objective: The aim of this study was to identify factors associated with distress experienced by physicians during their first coronavirus disease 2019 (COVID-19) triage decisions.

Methods: An online survey was administered to physicians licensed in New York State.

Results: Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8; P = 0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7; P = 0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio, 6.33; 95% confidence interval, 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87).

Conclusion: Approximately 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of experiencing severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.
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http://dx.doi.org/10.1017/dmp.2021.170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314063PMC
June 2021

Burnout among primary health care workers in Brazil: results of a multilevel analysis.

Int Arch Occup Environ Health 2021 Nov 31;94(8):1863-1875. Epub 2021 May 31.

University of São Paulo, Faculty of Medicine of Jundiaí, and Research Center in Primary Care - NUPAS, Faculty of Medicine Santa Marcelina, São Paulo, Brazil.

Purpose: Burnout among health care workers may hamper the quality of care and effectiveness of health systems. Hence, we examined the prevalence of burnout in primary care teams, including community health workers; and investigated associations between individuals' characteristics, team and primary care center factors, and burnout.

Methods: We carried out a cross-sectional study among primary care teams in the city of São Paulo, Brazil (n = 2940). We randomly selected 66 primary care centers. The Maslach burnout inventory was used to investigate burnout. We used multilevel modelling to examine the associations between individuals' characteristics, team and primary care center variables with burnout.

Results: We addressed 351 primary care teams, with 11.4% of participants presenting severe burnout. The variance in burnout among primary care workers was partially explained by individuals' characteristics, and by team and primary care center factors. Severe burnout was associated with the following: (1) individuals' characteristics: being black, being younger, a higher length of employment in primary care, and presenting a lack of feedback from supervisors; (2) team factors: working in deprived areas and not receiving the support of a multidisciplinary team; and (3) primary care center factors: inadequate infrastructure (less than one office available per team), and having a bad/very bad relationship with the community council.

Conclusions: To reduce burnout among primary care teams, stakeholders should: (1) train managers/supervisors on leadership styles that prioritize performance feedback, support, and communication skills; (2) allocate catchment areas to teams according to each community's vulnerability; (3) provide a multidisciplinary team to support primary care workers; and (4) offer suitable facilities and infra-structure.
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http://dx.doi.org/10.1007/s00420-021-01709-8DOI Listing
November 2021

Implications of Global and Local Inequalities in COVID-19 Vaccine Distribution for People With Severe Mental Disorders in Latin America.

JAMA Psychiatry 2021 09;78(9):945-946

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.

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http://dx.doi.org/10.1001/jamapsychiatry.2021.1416DOI Listing
September 2021

Schizophrenia incidence in Spain: More questions than facts.

Rev Psiquiatr Salud Ment (Engl Ed) 2021 May 21. Epub 2021 May 21.

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, Estados Unidos; Centro de Investigación Biomédica en Red Salud Mental (CIBERSAM).

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http://dx.doi.org/10.1016/j.rpsm.2021.05.002DOI Listing
May 2021

Explaining the Black-white depression paradox: Interrogating the Environmental Affordances Model.

Soc Sci Med 2021 05 22;277:113869. Epub 2021 Mar 22.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

The Environmental Affordances (EA) model posits that Black Americans' engagement with unhealthy behaviors (i.e. smoking, alcohol use, eating calorie-dense foods) to cope with stressor exposure may simultaneously account for their observed greater risk of chronic physical illness, and their observed equal or lesser prevalence of depression, relative to white Americans - the so-called "Black-white depression paradox." However, the specific mechanisms through which such effects might arise have been theorized and analyzed inconsistently across studies, raising concerns regarding the appropriateness of existing empirical tests of the model as well as the validity of the conclusions. We specify the two mechanisms most consistent with the EA model - 'Mediation-only' and 'Mediation and Modification' - and derive a priori predictions based on each. We systematically test these pathways using a subset of 559 participants of the Child Health and Development Study who were included in an adult follow-up study between 2010 and 2012 and self-identified as Black or white. Results failed to support either of the two mechanisms derived from the EA model, challenging the validity and utility of the model for explaining racial differences in depression; efforts to develop alternative hypotheses to explain the paradox are needed.
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http://dx.doi.org/10.1016/j.socscimed.2021.113869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119386PMC
May 2021

Antidepressant prescriptions and adherence in primary care in India: Insights from a cluster randomized control trial.

PLoS One 2021 19;16(3):e0248641. Epub 2021 Mar 19.

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America.

Background: The World Health Organization recommends that treatment of depression in low and middle-income countries with a scarcity of psychiatrists could be done in primary care and should include prescription of antidepressant medications for moderate and severe depression. Little is known, however, about the actual practices of antidepressant prescription by primary care physicians in low and middle-income countries, nor about adherence by people receiving such prescriptions. In a large study of primary care clinics in Goa, India, we examined the relationship of actual to recommended prescribing practices for depression, among all patients who screened positive for common mental disorder. We also examined other patient and clinic characteristics associated with antidepressant prescription, and self-reported adherence over a one-month period.

Methods: Patients attending 24 primary care clinics were screened for common mental disorders. Those who screened positive were eligible to enroll in a trial to assess the effectiveness of a collaborative stepped care (CSC) intervention for mental disorders. Physicians in the 12 intervention and 12 control clinics (usual care) were free to prescribe antidepressants and follow-up interviews were conducted at 2, 6 and 12 months. Screening results were shared with the physician, but they were blinded to the diagnosis generated later using a standardized diagnostic interview administered by a health counsellor. We categorized these later diagnoses as "moderate/severe depression", "mild depression or non-depression diagnosis", and "no diagnosis". We used a two-level hierarchical logistic regression model to examine diagnostic and other factors associated with antidepressant prescription and one-month adherence.

Results: Overall, about 47% of screened positive patients (n = 1320) received an antidepressant prescription: 60% of those with moderate/severe depression, 48% of those with mild depression or non-depression diagnosis, and 31% with no diagnosis. Women (OR 1.29; 95%CI 1.04-1.60) and older adults (OR 1.80; 95%CI 1.32-2.47) were more likely to receive an antidepressant prescription. While the overall rate of antidepressant prescription was similar in clinics with and without CSC, patients without any diagnosis were more likely to receive a prescription (OR 2.20 95% CI 1.03-4.70) in the usual care clinics. About 47% of patients adhered to antidepressant treatment for one month or more and adherence was significantly better among older adults (OR 3.92; 95% CI 1.70-8.93) and those who received antidepressant as part of the CSC treatment model (OR 6.10 95% CI 3.67-10.14) compared with those attending the usual care clinic.

Conclusion: Antidepressants were widely prescribed following screening in primary care, but prescription patterns were in poor accord with WHO recommendations. The data suggest under-prescription for people with moderate/severe depression; over-prescription for people with mild depression or non-depression diagnoses; and over-prescription for people with no disorders. For all diagnoses adherence was low, especially in usual care clinics. To address these concerns, there is an urgent need to study and develop strategies in primary care practices to limit unnecessary antidepressant prescriptions, target prescription for those patients who clearly benefit, and to improve adherence to antidepressant treatment. ClinicalTrials.gov Identifier: NCT00446407.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248641PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978355PMC
October 2021

Comparison of social cognition using an adapted Chinese version of the Reading the Mind in the Eyes Test in drug-naive and regularly medicated individuals with chronic schizophrenia and healthy controls in rural China.

Psychol Med 2021 Mar 16:1-13. Epub 2021 Mar 16.

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA.

Background: Social cognition has not previously been assessed in treatment-naive patients with chronic schizophrenia, in patients over 60 years of age, or in patients with less than 5 years of schooling.

Methods: We revised a commonly used measure of social cognition, the Reading the Mind in the Eyes Test (RMET), by expanding the instructions, using both self-completion and interviewer-completion versions (for illiterate respondents), and classifying each test administration as 'successfully completed' or 'incomplete'. The revised instrument (RMET-CV-R) was administered to 233 treatment-naive patients with chronic schizophrenia (UT), 154 treated controls with chronic schizophrenia (TC), and 259 healthy controls (HC) from rural communities in China.

Results: In bivariate and multivariate analyses, successful completion rates and RMET-CV-R scores (percent correct judgments about emotion exhibited in 70 presented slides) were highest in HC, intermediate in TC, and lowest in UT (adjusted completion rates, 97.0, 72.4, and 49.9%, respectively; adjusted RMET-CV-R scores, 45.4, 38.5, and 34.6%, respectively; all p < 0.02). Stratified analyses by the method of administration (self-completed v. interviewer-completed) and by education and age ('educated-younger' v. 'undereducated-older') show the same relationship between groups (i.e. NC>TC>UT), though not all differences remain statistically significant.

Conclusions: We find poorer social cognition in treatment-naive than in treated patients with chronic schizophrenia. The discriminant validity of RMET-CV-R in undereducated, older patients demonstrates the feasibility of administering revised versions of RMET to patients who may otherwise be considered ineligible due to education or age by changing the method of test administration and carefully assessing respondents' ability to complete the task successfully.
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http://dx.doi.org/10.1017/S003329172100043XDOI Listing
March 2021

Understanding Users' Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile.

Community Ment Health J 2022 Jan 1;58(1):111-120. Epub 2021 Mar 1.

New York State Psychiatric Institute, New York, NY, USA.

This study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users' perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system's incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users.
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http://dx.doi.org/10.1007/s10597-021-00800-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8408283PMC
January 2022

Measurement of Telomere Length for Longitudinal Analysis: Implications of Assay Precision.

Am J Epidemiol 2021 07;190(7):1406-1413

Researchers increasingly wish to test hypotheses concerning the impact of environmental or disease exposures on telomere length (TL), and they use longitudinal study designs to do so. In population studies, TL is usually measured with a quantitative polymerase chain reaction (qPCR)-based method. This method has been validated by calculating its correlation with a gold standard method such as Southern blotting (SB) in cross-sectional data sets. However, in a cross-section, the range of true variation in TL is large, and measurement error is introduced only once. In a longitudinal study, the target variation of interest is small, and measurement error is introduced at both baseline and follow-up. In this paper, we present results from a small data set (n = 20) in which leukocyte TL was measured twice 6.6 years apart by means of both qPCR and SB. The cross-sectional correlations between qPCR and SB were high at both baseline (r = 0.90) and follow-up (r = 0.85), yet their correlation for TL change was poor (r = 0.48). Moreover, the qPCR data but not the SB data showed strong signatures of measurement error. Through simulation, we show that the statistical power gain from performing a longitudinal analysis is much greater for SB than for qPCR. We discuss implications for optimal study design and analysis.
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http://dx.doi.org/10.1093/aje/kwab025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245883PMC
July 2021

The age pattern of the male-to-female ratio in mortality from COVID-19 mirrors that of cardiovascular disease in the general population.

Aging (Albany NY) 2021 02 7;13(3):3190-3201. Epub 2021 Feb 7.

Center of Human Development and Aging, New Jersey Medical School, Rutgers State University of New Jersey, Newark, NJ 07103, USA.

Males are at a higher risk of dying from COVID-19 than females. Older age and cardiovascular disease are also associated with COVID-19 mortality. To better understand how age and sex interact contributing to COVID-19 mortality, we stratified the male-to-female (sex) ratios in mortality by age group. We then compared the age-stratified sex ratios with those of cardiovascular mortality and cancer mortality in the general population. Data were obtained from official government sources in the US and five European countries: Italy, Spain, France, Germany, and the Netherlands. The sex ratio of deaths from COVID-19 exceeded one throughout adult life, increasing up to a peak in midlife, and declining markedly in later life. This pattern was also observed for the sex ratio of deaths from cardiovascular disease, but not cancer, in the general populations of the US and European countries. Therefore, the sex ratios of deaths from COVID-19 and from cardiovascular disease share similar patterns across the adult life course. The underlying mechanisms are poorly understood and warrant further investigation.
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http://dx.doi.org/10.18632/aging.202639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906174PMC
February 2021

The Nexus Between Telomere Length and Lymphocyte Count in Seniors Hospitalized With COVID-19.

J Gerontol A Biol Sci Med Sci 2021 07;76(8):e97-e101

Center of Human Development and Aging, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, USA.

Profound T-cell lymphopenia is the hallmark of severe coronavirus disease 2019 (COVID-19). T-cell proliferation is telomere length (TL) dependent and telomeres shorten with age. Older COVID-19 patients, we hypothesize, are, therefore, at a higher risk of having TL-dependent lymphopenia. We measured TL by the novel Telomere Shortest Length Assay (TeSLA), and by Southern blotting (SB) of the terminal restriction fragments in peripheral blood mononuclear cells of 17 COVID-19 and 21 non-COVID-19 patients, aged 87 ± 8 (mean ± SD) and 87 ± 9 years, respectively. TeSLA tallies and measures single telomeres, including short telomeres undetected by SB. Such telomeres are relevant to TL-mediated biological processes, including cell viability and senescence. TeSLA yields 2 key metrics: the proportions of telomeres with different lengths (expressed in %) and their mean (TeSLA mTL), (expressed in kb). Lymphocyte count (109/L) was 0.91 ± 0.42 in COVID-19 patients and 1.50 ± 0.50 in non-COVID-19 patients (p < .001). In COVID-19 patients, but not in non-COVID-19 patients, lymphocyte count was inversely correlated with the proportion of telomeres shorter than 2 kb (p = .005) and positively correlated with TeSLA mTL (p = .03). Lymphocyte count was not significantly correlated with SB mTL in either COVID-19 or non-COVID-19 patients. We propose that compromised TL-dependent T-cell proliferative response, driven by short telomere in the TL distribution, contributes to COVID-19 lymphopenia among old adults. We infer that infection with SARS-CoV-2 uncovers the limits of the TL reserves of older persons. Clinical Trials Registration Number: NCT04325646.
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http://dx.doi.org/10.1093/gerona/glab026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929343PMC
July 2021

Age of walking and intellectual ability in autism spectrum disorder and other neurodevelopmental disorders: a population-based study.

J Child Psychol Psychiatry 2021 09 28;62(9):1070-1078. Epub 2020 Dec 28.

UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA.

Background: Delayed walking is common in intellectual disability (ID) but may be less common when ID occurs with autism spectrum disorder (ASD). Previous studies examining this were limited by reliance on clinical samples and exclusion of children with severe motor deficits.

Objective: To examine in a population-based sample if age of walking is differentially related to intellectual ability in children with ASD versus other neurodevelopmental disorders (NDD).

Methods: Participants were from the nested Autism Birth Cohort Study of the Norwegian Mother, Father and Child Cohort Study (MoBa). Cox proportional hazards regression assessed if diagnosis (ASD n = 212 vs. NDD n = 354), continuous nonverbal IQ, and their interaction, were associated with continuous age of walking.

Results: The relationship between nonverbal IQ and age of walking was stronger for NDD than for ASD (Group × nonverbal IQ interaction, χ  = 13.93, p = .0002). This interaction was characterized by a 21% decrease in the likelihood of walking onset at any given time during the observation period per 10-point decrease in nonverbal IQ (hazard ratio = 0.79, 95% CI: 0.78-0.85) in the NDD group compared to 8% (hazard ratio = 0.92, 95% CI: 0.86-0.98) in the ASD group.

Conclusions: The finding that age of walking is less strongly related to low intellectual ability in children with ASD than in children without other NDDs supports the hypothesis that ID in ASD may result from heterogeneous developmental pathways. Late walking may be a useful stratification variable in etiological research focused on ASD and other NDDs.
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http://dx.doi.org/10.1111/jcpp.13369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236490PMC
September 2021

Disengagement From Early Intervention Services for Psychosis: A Systematic Review.

Psychiatr Serv 2021 01 25;72(1):49-60. Epub 2020 Nov 25.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City (Mascayano, van der Ven, Martinez-Ales, Restrepo Henao, Zambrano, Yang, Susser); Division of Behavioral Health Services and Policies, New York State Psychiatric Institute, New York City (Mascayano, Smith, Susser, Dixon); School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands (van der Ven); Epidemiology Group, National School of Public Health, Universidad of Antioquia, Medellín, Colombia (Restrepo Henao); Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa (Jones); George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis (Cabassa); Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York City (Yang).

Objective: Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

Methods: A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

Results: Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

Conclusions: Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.
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http://dx.doi.org/10.1176/appi.ps.201900375DOI Listing
January 2021

A Mechanism for Severity of Disease in Older Patients with COVID-19: The Nexus between Telomere Length and Lymphopenia.

medRxiv 2020 Oct 4. Epub 2020 Oct 4.

Background: Lymphopenia due to a plummeting T-cell count is a major feature of severe COVID-19. T-cell proliferation is telomere length (TL)-dependent and TL shortens with age. Older persons are disproportionally affected by severe COVID-19, and we hypothesized that those with short TL have less capacity to mount an adequate T-cell proliferative response to SARS-CoV-2. This hypothesis predicts that among older patients with COVID-19, shorter telomeres of peripheral blood mononuclear cells (PBMCs) will be associated with a lower lymphocyte count.

Methods: Our sample comprised 17 COVID-19 and 21 non-COVID-19 patients, aged 87(8) (mean(SD)) and 87 (9) years, respectively. We measured TL by the Telomere Shortest Length Assay, a novel method that measures and tallies the short telomeres directly relevant to telomere-mediated biological processes. The primary analysis quantified TL as the proportion of telomeres shorter than 2 kilobases. For comparison, we also quantified TL by Southern blotting, which measures the mean length of telomeres.

Results: Lymphocyte count (109/L) was 0.91 (0.42) in COVID-19 patients and 1.50(0.50) in non-COVID-19 patients (P < 0.001). In COVID-19 patients, but not in non-COVID-19 patients, lymphocyte count was inversely correlated with the proportion of telomeres shorter than 2 kilobases (P = 0.005) and positively correlated with the mean of telomeres measured by TeSLA (P = 0.03). Lymphocyte counts showed no statistically significant correlations with Southern blotting results in COVID-19 or non-COVID-19 patients.

Conclusions: These results support the hypothesis that a compromised TL-dependent T-cell proliferative response contributes to lymphopenia and the resulting disproportionate severity of COVID-19 among old adults. We infer that infection with SARS-CoV-2 uncovers the limits of the TL reserves of older persons.
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http://dx.doi.org/10.1101/2020.10.01.20205393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536885PMC
October 2020

Correction to: Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial.

Trials 2020 Oct 6;21(1):829. Epub 2020 Oct 6.

Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s13063-020-04776-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539443PMC
October 2020

Psychopathology among apprentice traditional health practitioners: A quantitative study from rural KwaZulu-Natal, South Africa.

Transcult Psychiatry 2021 08 6;58(4):486-498. Epub 2020 Oct 6.

Parnassia Psychiatric Institute, The Hague, The Netherlands.

Sociocultural context seems to influence the epidemiology, phenotype, treatment, and course of psychosis. However, data from low- and middle-income countries is sparse. This research is part of a multidisciplinary and multimethod study on possible mental disturbances, including hallucinations, among (apprentice) traditional health practitioners (THPs) who have experienced the "ancestral calling to become a THP" in rural KwaZulu-Natal, South Africa. The aim of the current article is to examine whether the calling-related experiences can be assessed according to a psychiatric taxonomy. We included individuals who were identified with the calling and who were undergoing training to become a THP (). IsiZulu-speaking formal mental health practitioners conducted thorough psychiatric interviews that measured psychological experiences with and without distress using the Community Assessment of Psychic Experiences, and psychiatric symptoms and disorders using the Schedule for Clinical Assessment in Neuropsychiatry. Of the 48 individuals who participated, 92% had psychotic experiences (PE), causing distress in 75%; and 23% met DSM-5 criteria for an unspecified psychotic disorder (15%) or mood disorder (8%). In conclusion, in rural KwaZulu-Natal, the ancestral calling may resemble phenomena that psychiatry would understand in the context of psychosis, ranging from subclinical PE to clinical psychotic disorder. might have a beneficial influence on the course of psychotic symptoms in some individuals, potentially because it reduces stigma and promotes recovery. Further multidisciplinary research is needed to investigate the psychopathology of the apprentice THPs and the underlying processes of .
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http://dx.doi.org/10.1177/1363461520949672DOI Listing
August 2021

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State.

Psychiatr Serv 2020 11 16;71(11):1151-1157. Epub 2020 Sep 16.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York (Mascayano, van der Ven, Martinez-Ales, Susser); Division of Behavioral Health Services and Policies, New York State Psychiatric Institute, New York (Mascayano, Basaraba, Bello, Nossel, S. Smith, T. Smith, Wall, Susser, Dixon); School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands (van der Ven); Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa (Jones); Silberman School of Social Work, Hunter College, City University of New York, New York (Lee). Editor Emeritus Howard H. Goldman, M.D., Ph.D., served as decision editor on the manuscript.

Objective: Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

Methods: This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

Results: The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

Conclusions: Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.
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http://dx.doi.org/10.1176/appi.ps.202000025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237377PMC
November 2020
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