Research Spotlights: December 2022

Sustained Effects of Mindfulness Interventions During Pregnancy in a Diverse Pool of Women

Depression is a public health crisis and specifically, prenatal depression affects 12-27% of individuals and is a strong predictor of persistent, postnatal depression. Based on clinical guidelines, all pregnant and postpartum women are screened for depression and given referrals if necessary. Mental health screening is a pivotal part of maternal mental health care but there are limited scalable and affordable interventions readily accessible. Previous research has primarily focused on non-Hispanic White women and mainly followed study participants for 1-year postpartum. Recently published research supported by the NHLBI, NIMH, and others examined the sustained effectiveness of a prenatal mindfulness intervention, with proven benefits during the early postpartum period (6 months postpartum), on reducing maternal depressive symptoms long-term (8 years postpartum).

Researchers assigned a sample of low-income pregnant women (n=162) who were racially and ethnically diverse to either receive an 8-week mindfulness-based group intervention during pregnancy (MIND) focused on stress, depression, healthy eating, and gestational weight gain or treatment as usual (TAU). TAU participants received standard prenatal care and any mental health care they sought out on their own. During the observational postnatal study, repeated evaluations of depressive symptoms were self-reported using the Patient Health Questionnaire-9 at baseline, post-intervention, and across an 8-year follow-up period. The final follow-up occurred during the COVID-19 pandemic and presented an additional opportunity to detect how increased environmental stressors affected study participants.

Two linear mixed effects models were used to assess the effect of the main intervention as well as the presence and severity of continuous depressive symptoms over time. Results showed that depressive symptoms for MIND and TAU women were comparable at baseline but were significantly lower among women in MIND compared to TAU at their annual assessment across the 8-year follow-up period, including during the pandemic. These results suggest that effects of this group-based psychosocial intervention delivered during pregnancy may have long-lasting effects well beyond the perinatal period.

This study has some limitations. First, the participants assigned to the MIND and TAU groups differed on weeks of gestation at enrollment and time between baseline and follow-up assessments. Second, the study did not assess clinical diagnoses of depression and is limited by the self-reporting of depressive symptoms. Third, information regarding mental health care received outside of the study was not amassed and therefore, women who participated in MIND could have received additional psychological support which contributed to their lower levels of depressive symptoms over time.

In conclusion, there are sustained well-being benefits to investing in mindfulness-based interventions during the prenatal period. Additionally, the findings from this study provide evidence that these types of brief psychosocial, group-based interventions, delivered during pregnancy, may enhance skills that support positive maternal mental health outcomes for lower-income and racially and/or ethnically diverse women, well beyond the perinatal period.

Roubinov DS, Epel ES, Coccia M, Coleman-Phox K, Vieten C, Adler NE, Laraia B, Bush NR. Long-term effects of a prenatal mindfulness intervention on depressive symptoms in a diverse sample of women. J Consult Clin Psychol. 2022 Nov 28. doi: 10.1037/ccp0000776. Epub ahead of print. PMID: 36441994.

Adolescent substance use: Improving detection, prevention, and interventions

Over the past decade, there has been an increase in the popularity and consumption of non-traditional nicotine via electronic nicotine delivery systems (vaping), cannabis (vaped and edible), and misuse of prescription opioids—collectively termed “ECPO” by the authors—by adolescents (ages 13-18). The uptick in popularity of has come with the challenge of medical providers and caregivers being able to identify adolescent users due to the lack of immediately conspicuous physical or behavioral signs after use. It is therefore difficult for providers and caregivers to target screening and provide the appropriate intervention(s), despite evidence that use of these substances during adolescence may adversely impact long-term brain development structure and function. In response to this challenge, a recent publication supported by the NIAAA and NIDA, provides a brief screening, detection, prevention, and intervention framework to help identify adolescents at risk.

Based on empirical reviews, as well as findings from published preclinical studies, the authors discuss the risks posed by consistent or heightened ECPO use in the context of the specific attributes of the substances themselves as well as additional substances involved in ECPO delivery. Overall, the findings from this review suggests that delaying or deterring the onset of ECPO use is the best approach to mitigating the risk of neurodevelopmental harm posed by these substances. The authors further urge providers to update their screening criteria, given that physical and behavioral indicators for vaped or edible EPCO substances present differently than more traditional alcohol or cigarette use. Detection of ECPO use is further complicated by the time constraints providers have for these clinical visits, which are often brief visits. To combat this challenge, they advise providers to use the following screening tools: the CRAFFT 2.1+N questionnaire, the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD), and the Screening to Brief Intervention (S2BI) tool, in addition to laboratory urinalyses.

Prevention approaches discussed in this publication include parental/caregiver education regarding EPCO use, advising providers and pharmacies to clarify practical steps regarding tapering then discontinuing adolescent prescription opioid use, and addressing misconceptions via public messaging. There are unique outreach challenges posed by EPCO use, stemming from certain misconceptions, including the myths that vaped or edible cannabis is safer than combustible cannabis, and that e-cigarettes contain only flavoring and water. Another challenge is the conflation of legalization with safety for all end users. Prescription opioids remain a risk if there is a lack of supervised prescription use in the home. It was also noted that there is a heightened risk of substance use/misuse for adolescents who belong to a racial, ethnic, or sexual minority group, and the authors advise certain key considerations for providers working with adolescents belonging to these groups, including the application of a culturally attuned assessment when integrated with brief interventions, as well as the client-centered approach of motivational interviewing.

Noting the dearth of data on this emerging area of substance use research, the authors call for further investigation into the policy, neurobiological, biobehavioral, and social aspects of ECPO use, to support harm reduction, patient education, and patient-provider communication.

Dash GF, Holt L, Kenyon EA, Carter EK, Ho D, Hudson KA, Feldstein Ewing SW. Detection of vaping, cannabis use, and hazardous prescription opioid use among adolescents. Lancet Child Adolesc Health. 2022 Nov;6(11):820-828. doi: 10.1016/S2352-4642(22)00212-7. Epub 2022 Aug 26. PMID: 36030794; PMCID: PMC9588707.

Cash incentives can help boost weight-loss programs in individuals living in low-income neighborhoods

The prevalence of obesity in adults has been increasing over the few decades in the U.S., with a substantially higher percentage of racial and ethnic minority groups being affected. Obesity is known to contribute to diseases such as diabetes, heart disease, stroke, and cancer, and comes with a high economic burden attributable to these obesity-related illnesses. Further compounding this problem is that individuals with obesity are more likely than their “normal-weight” counterparts to experience social stigma, including employment discrimination, further exacerbating health and socioeconomic disparities. Currently there are evidence-based strategies for weight loss however, these strategies are often underused in practice. In a recent study, supported by the NIMHD, NCATS, and others sought to determine if using a behavioral economics approach, which applied economic and psychology concepts through financial incentives, could be an effective tool for weight loss. The authors hypothesized that goal-directed incentives would lead to greater and more sustained weight loss than outcome-based incentives or the provision of behavior change resources alone.

To test their hypothesis, the researchers conducted a randomized clinical trial, they called the Financial Incentives for Weight Reduction (FIReWoRk). In brief, weight-loss efforts were tracked for up to a year in low-income (median neighborhood income less than $40,000/year), predominately Hispanic men and women with an average pre-trial body mass index of 37.95 (n = 668, 72% Hispanic, 14.8% Black, 81% female, mean age = 47.7). All participants were randomly assigned to one of three intervention groups: 1) goal-directed incentives where they received resources and the evidence-based behavior change was linked with financial incentives, 2) outcome-based incentives where they received resources and the percentage of weight loss was linked with financial incentives, or 3) a resources-only group. All patients were provided with weight management resources, including a 1-year commercial weight loss program membership, self-monitoring tools (digital scale, food journal, and wearable fitness tracker), health education, and monthly one-on-one check-in visits. For those receiving cash incentives, payments were made monthly dependent on weight-loss or meeting goals.

The results from this study showed that after 6 months approximately half (49%) of participants in the in the outcome-based incentive group lost at least 5% of their original body weight, with this percentage reducing to 41% after the one year of follow-up. Similarly, 39.0% of participants in the goal-directed group lost 5% of their starting weight after six months, with this percentage increasing to almost 42% after 12 months of monitoring. The percentage of participants in the resources-only group that had a 5% reduction in their original body weight was 22% at 6 months, with this percentage increasing to almost 33% after one year. Mean earned incentives was $440.44 in the goal-directed group and $303.56 in the outcome-based group.

Future studies are needed that consider other groups identified by federal health agencies as disproportionately impacted by obesity (e.g., Blacks, Native Americans, U.S. military veterans). Additionally, further research is needed to determine if these weight losses are maintained over several years and if there may be a need for periodic "booster" incentives to sustain long-term reductions in weight.

In conclusion, this study provides evidence that offering incentives, such as cash rewards, even if only in the short-term, can help individuals with obesity living in low-income environments lose weight. Incentives tied to actual weight lost (outcome-based) performed better in the short term as compared to goal-based incentives however, this effect evened out after a year with both outcome and goal-based incentives having an equivalent percentage of participants with 5% or more decrease in their original weight. Of note, even offering resources and tools without cash incentives can also have a beneficial impact on weight-loss, albeit not as effectively as with the cash incentive.

Ladapo JA, Orstad SL, Wali S, Wylie-Rosett J, Tseng CH, Chung UYR, Cuevas MA, Hernandez C, Parraga S, Ponce R, Sweat V, Wittleder S, Wallach AB, Shu SB, Goldstein NJ, Jay M. Effectiveness of Goal-Directed and Outcome-Based Financial Incentives for Weight Loss in Primary Care Patients With Obesity Living in Socioeconomically Disadvantaged Neighborhoods: A Randomized Clinical Trial. JAMA Intern Med. 2022 Dec 5. doi: 10.1001/jamainternmed.2022.5618. Epub ahead of print. PMID: 36469353.