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Research Spotlights: May 2022

Addressing insomnia among Black women using cognitive behavioral therapy for insomnia delivered via a tailored, internet-based intervention

Insomnia is a significant public health concern, and one that disproportionately impacts Black women. Although cognitive behavioral therapy for insomnia (CBT-i) is a standard treatment for this condition, there is limited research on the efficacy of CBT-i among this population. In a recently published study, supported by the NIA, NCI, PCORI, and others demonstrates the importance of developing evidence-based, tailored treatments for addressing insomnia symptoms among Black women.

The research team conducted a 3-arm randomized trial where participants received either the standard version of an automated internet-delivered treatment for insomnia called Sleep Healthy Using the Internet (SHUTi), a stakeholder-informed, tailored version of the program for Black women (SHUTi-BWHS), or patient education about sleep. Briefly, SHUTi is a 6-session program (45-60 minutes per session, delivered over 6 to 9 weeks), that incorporates all elements of CBT-i. The SHUTi-BWHS was developed with input from Black women with lived experiences of insomnia, a sleep physician from a medical center serving predominately racial/ethnic minority groups, a national health organization sleep researcher, and the study investigators. The researchers examined the impact of the programs on insomnia severity and the relationship between program completion and insomnia symptoms, among Black women with insomnia disorder, using an equal allocation ratio. Participants (n = 333) were recruited from the Black Women’s Health Study, a national cohort study established in 1995, and includes participants from across the U.S. The primary outcome was insomnia severity (as measured using the Insomnia Severity Index). Participants were assessed baseline (time 1), time 2 (postintervention, approximately 9 weeks after time 1), and time 3 (approximately 6 months after time 2). Researchers also captured detailed sleep information via online sleep diaries, sleep quality using the Pittsburgh Sleep Quality Index, and intervention completion rates (participants who completed all 6 SHUTi sessions).

Using factorial mixed-effects linear model analyses, researchers compared improvement in the treatment groups to the usual care group, and to one another. They found that participants in both treatment groups (SHUTi and SHUTi BWHS) showed significant improvements in insomnia severity, secondary sleep outcomes (as measured via sleep diaries), and sleep quality, relative to participants receiving patient education only. Significantly more participants randomized to the SHUTi-BWHS program completed the full intervention, and participants that completed the entire program, in either treatment condition showed significantly greater improvements with respect to their insomnia symptoms and other sleep-related outcomes than non-completers. The study findings have some limitations including that the study sample included older Black women (mean age = 59.5) with a higher socioeconomic background, thus findings may not generalize to the broader population of Black women in the U.S. Additionally, the study was not powered to detect smaller differences between SHUTi and SHUTi-BWHS.

In summary, this study provides an important examination of the role of tailored, internet-delivered interventions for insomnia among Black women. This research highlights the need for creating and validating interventions that are co-developed with the populations they are intended to serve, and for developing accessible, scalable, and evidence-based interventions for reducing insomnia and promoting quality sleep among historically underserved populations.

Citation:
Zhou ES, Ritterband LM, Bethea TN, Robles YP, Heeren TC, Rosenberg L. Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial. JAMA Psychiatry. 2022 Apr 20:e220653. doi: 10.1001/jamapsychiatry.2022.0653. Epub ahead of print. PMID: 35442432; PMCID: PMC9021979.

Social connections influence the brain structure of nonhuman primates

Social relationships are driven by factors like status and alliances and in the context of primates which thrive in large complex social groups. The large computational demands of living in large, complex social groups has been hypothesized to be a crucial factor driving the evolution of the primate brain size. However, whether and how the diverse components of primates’ natural social lives relate to brain structure remain largely unexplored., these factors may be linked to primate brain size over time. In a recent study funded by the NIMH, NIA, NSF, and others sought to understand the relationship between primate neuroanatomy and social factors in free-ranging rhesus macaques.

In this study, researchers studied a semi-free colony of adult rhesus macaques (n = 68, aged 4 years or older) that had naturally formed social units. The researchers collected behavioral data via recordings of detailed interactions of the social group including: social status, number of grooming partners, physical distance with other monkeys, connectedness to popular monkeys in the network, and "betweenness" (ability to act as a bridge between unconnected social network members). Brain scans were collected for every individual in the social group, including 35 juvenile and infant macaques.

Analysis of the data from the adult monkeys showed that the individuals that had more grooming partners also had increased volumes in certain brain structures, the mid-superior temporal sulcus and ventral-dysgranular insula, areas both previously found to be important for social cognition in humans and non-human primates. No other correlations were found between brain structure and other variables, such as social status. Interestingly, when the researchers looked at the brain images of young macaques, they did not see these size differences, indicating these differences likely arose during development.

In summary, this study provides indicates that social network size predicts the size of specific brain regions, the mid-superior temporal sulcus and ventral dysgranular insula, further supporting the hypothesis that the complex nature of a primates’ social environment as a key influencer of evolutionary neocortex expansion.

Citation:
Testard C, Brent LJN, Andersson J, Chiou KL, Negron-Del Valle JE, DeCasien AR, Acevedo-Ithier A, Stock MK, Antón SC, Gonzalez O, Walker CS, Foxley S, Compo NR, Bauman S, Ruiz-Lambides AV, Martinez MI, Skene JHP, Horvath JE, Unit CBR, Higham JP, Miller KL, Snyder-Mackler N, Montague MJ, Platt ML, Sallet J. Social connections predict brain structure in a multidimensional free-ranging primate society. Sci Adv. 2022 Apr 15;8(15):eabl5794. doi: 10.1126/sciadv.abl5794. Epub 2022 Apr 13. PMID: 35417242; PMCID: PMC9007502.

Socioeconomic factors affect patient outcomes for those being treated with pharmacotherapy for depression despite receiving equal access to care

Recently published research supported by the NIMH, NICHD, and others examined the impact of socioeconomic factors on pharmacotherapy treatment outcomes among adults with major depressive disorder (MDD). The research suggests that individuals who are socioeconomically disadvantaged (e.g., no college degree, unemployed, low income) demonstrate worse mental health outcomes than persons with higher socioeconomic status.

In order to examine the impact of socioeconomic variables on MDD pharmacotherapy treatment the researchers used data from the Combining Medications to Enhance Depression Outcomes (CO-MED) study, performed from March 2008 to April 2014, to create Bayesian hierarchical models of treatment response trajectories. MDD Patients (N=665, ages 18-75) were randomly assigned to one of three, antidepressant treatments for 12 weeks. Treatment visits were held at baseline (week 0) and weeks 4,8, and 12, and dosage was modified in response to a patient’s score on the Quick Inventory of Depressive Symptomology-Clinician Rated (QIDS-SR). Patients were seen by the same provider and center to control for clinical variables of financial cost, treatment access, quality of care, and insurance. Thus, the effects of education, employment, race-ethnicity, and income on treatment outcomes were the primary focus of the evaluation.

Lack of a college education (<16 years of schooling), being non-White, and being unemployed were associated with less improvement in MDD symptoms by week 12. Treatment outcomes showed greater improvements for patients with higher incomes. Patients with incomes at the 25th percentile of the income distribution curve had 4.8% less improvement compared with those with incomes at the 75th percentile. Due to the linked association of the variables, a comparison between response trajectories for patients who were White, had a college degree, were employed with an income at the 75th percentile and those who were non-White, no college degree, unemployed, and an income at the 25th percentile was conducted and found that the latter group had 25.9% less improvement in symptoms by week 12 (end of treatment). In summary, researchers found that socioeconomic characteristics such as race-ethnicity, education, employment, and income have substantial effects on mental health outcomes and that these effects are independent of access and quality of care, treatment costs, and insurance coverage. These findings suggest that socioeconomic variables must be leveraged as predictors of outcomes to inform individualized treatment approaches.

Citation:
Mills JA, Suresh V, Chang L, Mayes T, Croarkin PE, Trivedi MH, Strawn JR. Socioeconomic Predictors of Treatment Outcomes Among Adults with Major Depressive Disorder. Psychiatr Serv. 2022 Mar 31:appips202100559. doi: 10.1176/appi.ps.202100559. Epub ahead of print. PMID: 35354325.