abstract / Anatomy / Doctoral / Doctor of Philosophy

Major depressive disorder (MDD) is a prevalent and disabling disorder worldwide and in Hong Kong. It can occur alone or as a psychiatric sequelae of stroke known as post stroke depression (PSD). Our recent randomized controlled trial (RCT) found that additional dense cranial electroacupuncture stimulation (DCEAS) produced significantly greater improvement on depressive symptoms in patients with MDD compared to conventional antidepressants alone. However, the effectiveness of DCEAS on PSD and the underlying neural mechanism of its antidepressant effects remain unclear and need further investigation. This thesis consisted of three studies aimed to evaluate the efficacy of DCEAS as an additional therapy in PSD and to explore the neuroimaging correlates of DCEAS in MDD using PET and fMRI modalities. The purpose of Study 1 was to examine whether additional DCEAS was effective in treating PSD. A single blind RCT was conducted in 43 PSD patients treated with antidepressants and same body acupuncture combined with sham or active DCEAS with 3 acupuncture sessions per week for 4 weeks. Clinical outcomes included the Hamilton Depression Rating Scale 17-Item (HAMD-17), Clinical Global Impression - Severity Scale (CGI-S), and Barthel Index (BI).The results showed that DCEAS significantly reduced HAMD-17 at week 1, CGI-S at week 1 and endpoint whereas BI was more significantly decreased in control group. A combination of DCEAS and body acupuncture can be considered as an augmenting treatment for PSD. Study 2 aimed to explore the potential effects of DCEAS in regulating abnormal glucose metabolism in patients with MDD using 18F-FDG PET/CT. A single blind RCT was conducted in 25 MDD patients treated with antidepressants combined with sham or active DCEAS with 3 acupuncture sessions per week for 6 weeks. Clinical outcomes were measured using the HAMD-17, Zung Self-Rating Depression Scale (SDS), CGI-S and Insomnia Severity Index (ISI). There was a significant difference on the slope in SDS in linear mixed model analysis, indicating a faster improvement in subjective depressive symptoms by DCEAS. While the increased 18F-FDG signals in the cerebellum were normalized in both groups, the reversion of the reduced 18F-FDG signals in the left prefrontal cortex was only observed in DCEAS-treated patients, suggesting that additional DCEAS could more vigorously improve abnormal brain glucose metabolism in MDD. The purpose of Study 3 was to further investigate the neuropsychological and functional neuroimaging correlates of the antidepressant effects of DCEAS in the same pool of MDD subjects in Study 2 using fMRI with sad-face paradigm. The sad-face stimulation increased BOLD signals in an extensive neural network of the brain, including the frontal, temporal, parietal, limbic system and cerebellum. Additional DCEAS extensively suppressed the abnormal BOLD signals in these brain regions, more apparently in left caudate and cingulate, whereas sham treatment had slightly suppressive effects in fewer brain regions, suggesting that additional DCEAS could more robustly alter the biases towards sadness in MDD. In conclusion, DCEAS additional treatment is more effective in reducing depressive symptoms in patients with PSD, improving brain glucose metabolism and normalizing the abnormal neural activation due to biases towards sadness in patients with MDD. / published_or_final_version / Chinese Medicine / Doctoral / Doctor of Philosophy

Depression research demonstrates that self-focused processing, such as rumination, causes and maintains depressive disorders (Pyszczynski & Greenberg, 1987; Kuhl & Helle, 1986; Nolen-Hoeksema, 1987), while emotional processing literature shows beneficial effects to self-focus under some circumstances (Rachman, 1980; Foa & Kozak, 1986; Pennebaker, 1989). Therefore, it seems that self-focus is not inherently detrimental; rather, the way a person self-focuses could differentiate between unhealthy rumination and healthy emotional processing. Rude, Maestas, and Neff (2006) demonstrated that when the wording of a well-known rumination measure was altered to reduce judgment, the measure no longer correlated with depression. Mindfulness approaches that emphasize a non-judgmental acceptance of one's experience have produced beneficial outcomes (Baer, 2003), thus corroborating this finding. This dissertation investigated the role of acceptance in emotional recovery from a distressing event. It was hypothesized that encouraging participants to process emotions in an accepting manner would help them recover from a dysphoric mood more quickly than participants not given acceptance instructions or those given instructions to evaluate and change their emotions. Recovery was defined as return to baseline on measures of heart rate, skin conductance, skin temperature, self-reported positive and negative affect, and rumination (cognitive priming). In addition, the study investigated whether differences in the effects of emotional processing condition would be greatest for participants with low trait acceptance of emotions or high trait rumination. As predicted, Acceptance participants reported less negative affect than Control participants at the end of the study. There were no significant differences on negative affect between Acceptance and Evaluation conditions, however. Hypothesized differences in recovery as measured by heart rate, skin conductance, skin temperature, positive affect, and rumination were not found. As predicted, trait rumination and emotional acceptance interacted with processing condition for negative mood and heart rate: Acceptance and Evaluation conditions reduced negative mood more than the Control group for participants low in trait Emotional Acceptance, and the Acceptance condition reduced heart rate for high ruminators more than the Control group. Interestingly, and contrary to prediction, Acceptance participants showed evidence of greater priming of failure-related words than the other two groups on the reaction time measure. / text

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<p> Contacting one&rsquo;s values and engaging in behavior consistent with those values, referred to as valuing, is associated with improved physical and mental health (Nygren et al., 2005), increases in quality of life (Plumb &amp; Hayes, 2008), and increases in overall well-being (Reker et al., 1987), among many other positive outcomes. But those areas of life that are valued tend to elicit unwanted, negatively evaluated experiences, often resulting in experiential avoidance (Michelson et al., 2001). Experiential avoidance has been associated with the etiology and maintenance of many psychological struggles, particularly anxiety-related struggles (Kashdan et al., 2006; Eifert &amp; Forsyth, 2007; Hayes et al., 1999; Hayes et al., 1996). Given that anxiety is a negatively-evaluated experience that is often avoided, exploring the relationships between anxiety, experiential avoidance, and valuing appeared needed. The current study examines the relationships between anxiety, experiential avoidance, and valuing with college students using both retrospective assessments through initial questionnaires and immediate assessments through the use of ecological momentary assessment. As predicted, results indicated a significant positive relationship between anxiety and experiential avoidance. Results also indicated a negative relationship between experiential avoidance and valuing. Further, anxiety disrupted progress toward values the most when experiential avoidance was high while anxiety and experiential avoidance both independently facilitated more perceived obstacles toward values. Implications for future studies using of multiple methods of assessment, including ecological momentary assessment, along with a multidimensional conceptualization of valuing, are discussed.</p>

<p> The dynamic mental health landscape has placed undue strain on hospitals, providers, and the community at large, resulting in gross inequities in access to care for underserved populations. This business plan proposes the establishment of a Los Angeles area non-profit community mental health clinic, embedded with a mission to accept adult patients suffering from co-occurring mental health and chronic medical conditions, regardless of insurance status and ability to pay. Under the Patient Centered Medical Home model, the aim of the Clinic will be to treat patients holistically by incorporating an interdisciplinary team of clinicians to ensure optimal health outcomes. While this plan acknowledges the challenges in serving indigent populations, the Clinic will contract with Medi-Cal and commit to continuous fundraising efforts to remain financially sustainable in order to improve the health of vulnerable Angelenos.</p>

<p> Severely mentally ill adults are a historically underserved population that tends to be highly resistant to taking psychiatric medications. Although medications generally help to decrease the severity of symptoms and lower risk of relapse/hospital readmission, they also negatively impact sense of self and identity, and lead to unwanted side effects. Non adherence frequently leads to involuntary hospitalizations, where a medication adherence intervention is needed. In order to make a case for a medication adherence intervention, regression analyses were conducted on an inpatient psychiatric sample of 178 adults diagnosed with severe mental illnesses in order to determine predictive relationships between symptom severity upon admission, frequency of hospital readmission, medication adherence/non-adherence, and length of hospital stay (LOS). Results yielded insignificant findings, which is informative and even compelling due to medications being considered the gold standard in inpatient psychiatric care. Results were limited by medication adherence being measured dichotomously, and confounds related to ethnicity, family involvement, and substance abuse. Post-hoc analyses yielded significant relationships between pretest symptom severity and length of stay, as well as significance between medication non-adherence and elevations on the symptoms: Conceptual Disorganization, Grandiosity, Suspiciousness, and Motor Retardation, which indirectly support concerns about severely mentally ill adults not taking medications due to concerns related to autonomy and distrust of providers. Implications and future research and practice are also discussed.</p>

<p> Children who show signs of depression are at greater risk of having depression as adults as well as developing comorbid conditions. A multi-tiered system of support (MTSS) approach is currently the best evidence-based method for addressing behavioral and mental health concerns in a school setting. At this time, few research-based interventions exist that adequately address internalizing behaviors such as those associated with depression. <i> Strong Kids</i> is an evidence-based social-emotional learning curriculum that can be used at both the universal and secondary levels of prevention. It is designed to address internalizing behaviors; however, it has only been tested as one chronological series of lessons. This makes immediate response to a student&rsquo;s need &ndash; a hallmark of secondary prevention in MTSS &ndash; challenging because the Strong Kids program can take a minimum of 6 weeks for delivery. The current single-case design research evaluated the delivery of <i>Strong Kids</i> in an elementary school on a continuously rotating 4-week basis, such that students referred for the intervention began at the beginning of any given week and continued to receive the intervention until all lessons were received. Three hypotheses were tested: (a) Students at risk for developing depressive disorders would show reduced risk of depression following the <i>Strong Kids</i> intervention; (b) this intervention would be effective for students regardless of the lesson on which they begin the intervention; and, (c) any differential effects among students beginning the intervention during different weeks would be small and not reach the level of clinical significance. The obtained findings and implications for school practices are discussed.</p>

<p> The expansion of the parity law for mental health benefits under the Patient Protection Affordable Care Act (PPACA) along with the increased mental and/or behavioral health issue among American youth has established a need for various health services to mitigate the mental and/or behavioral health problem. The L.A. Children&rsquo;s Music Therapy Center, LLC, will be established to provide music therapy as an alternative or complementary form of medicine for individuals that are under 17 years of age with mental and/or behavioral health disorders. Additional regulations under the PPACA may potentially increase the use of mental health services and clinical evidence has shown that music therapy has resulted in improved health outcomes for various disorders. L.A. Children&rsquo;s Music Therapy Center, LLC, will focus on providing music therapy services within Los Angeles County for private clients in the community as well as contracting services for private and group organizations.</p>

<p> Nursing students often harbor negative stereotypes and feel unknowledgeable and unprepared to work with mentally ill people. In addition, nursing students rarely choose the psychiatric specialty as a career option. A quantitative quasi-experimental study was conducted to examine nursing student feelings about engaging those with behavioral health problems. Over 300 nursing students in eight Bachelor of Science in Nursing professional nursing programs were surveyed on the first and last day of their program&rsquo;s psychiatric mental health nursing course (the independent variable). A valid and reliable survey instrument was used to collect nursing student responses characterizing attitudes, impressions of knowledge and preparedness, and career interests relative to psychiatric nursing. This work was supported by the theoretical tenants of Labeling Theory, Benner&rsquo;s Model, and Peplau&rsquo;s Theory on Interpersonal Relations. Statistical Package for Social Sciences software was used for exploration of the data. Data examination included descriptive analysis and paired <i> t</i> tests of four component subscales identified by the survey tool authors which were associated with the research questions and research hypotheses in this study. The results indicated nursing students manifest negative attitudes and a moderate sense of knowledge of and preparedness for interacting with the mentally ill. In addition, nursing students had a low interest in behavioral health as a career path. However, significant improvements in all of these factors except the latter were observed at the end of the psychiatric mental health nursing course. Nurse educators may use the information generated from this project to modify psychiatric nursing courses for fostering improvement in student feelings about the mental health specialty.</p>