Our brains are made of the same stuff, despite DNA differences

Gene expression databases reveal “consistent molecular architecture”

Despite vast differences in the genetic code across individuals and ethnicities, the human brain shows a “consistent molecular architecture,” say researchers supported by the National Institutes of Health. The finding is from a pair of studies that have created databases revealing when and where genes turn on and off in multiple brain regions through development counselor ceus

“Our study shows how 650,000 common genetic variations that make each of us a unique person may influence the ebb and flow of 24,000 genes in the most distinctly human part of our brain as we grow and age,” explained Joel Kleinman, M.D., Ph.D., of the National Institute of Mental Health (NIMH) Clinical Brain Disorders Branch.

Kleinman and NIMH grantee Nenad Sestan, M.D., Ph.D. of Yale University, New Haven, Conn., led the sister studies in the Oct. 27, 2011 issue of the journal Nature.

“Having at our fingertips detailed information about when and where specific gene products are expressed in the brain brings new hope for understanding how this process can go awry in schizophrenia, autism and other brain disorders,” said NIMH Director Thomas R. Insel, M.D.

Both studies measured messenger RNAs or transcripts. These intermediate products carry the message from DNA, the genetic blueprint, to create proteins and differentiated brain tissue. Each gene can make several transcripts, which are expressed in patterns influenced by a subset of the approximately 1.5 million DNA variations unique to each of us. This unique set of transcripts is called our transcriptome – a molecular signature that is unique to every individual. The transcriptome is a measure of the diverse functional potential that exists in the brain.

Both studies found that rapid gene expression during fetal development abruptly switches to much slower rates after birth that gradually decline and eventually level off in middle age. These rates surge again as the brain ages in the last decades, mirroring rates seen in childhood and adolescence, according to one of the studies. The databases hold secrets to how the brain’s ever-changing messenger chemical systems, cells and development processes are related to gene expression patterns through development.

For example, if a particular version of a gene is implicated in a disorder, the new resources might reveal how that variation affects the gene’s expression over time and by brain region. By identifying even distant genes that may be turning on and off in-sync, the databases may help researchers discover whole modules of genes involved in the illness. They can also reveal how variation in one gene influences another’s expression.

Prefrontal cortex

Kleinman’s team focused on how genetic variations are linked to the expression of transcripts in the brain’s prefrontal cortex, the area that controls insight, planning and judgment, across the lifespan. They studied 269 postmortem, healthy human brains, ranging in age from two weeks after conception to 80 years old, using 49,000 genetic probes. The database on prefrontal cortex gene expression alone totals more than 1 trillion pieces of information, according to Kleinman.

Among key findings in the prefrontal cortex:
Individual genetic variations are profoundly linked to expression patterns. The most similarity across individuals is detected early in development and again as we approach the end of life.

Different types of related genes are expressed during prenatal development, infancy, and childhood, so that each of these stages shows a relatively distinct transcriptional identity. Three-fourths of genes reverse their direction of expression after birth, with most switching from on to off.

Expression of genes involved in cell division declines prenatally and in infancy, while expression of genes important for making synapses, or connections between brain cells, increases. In contrast, genes required for neuronal projections decline after birth – likely as unused connections are pruned.

By the time we reach our 50s, overall gene expression begins to increase, mirroring the sharp reversal of fetal expression changes that occur in infancy.

Genetic variation in the genome as a whole showed no effect on variation in the transcriptome as a whole, despite how genetically distant individuals might be. Hence, human cortexes have a consistent molecular architecture, despite our diversity.


In previous studies, Kleinman and colleagues have found that all genetic variations implicated to date in schizophrenia are associated with transcripts that are preferentially expressed in the fetal brain. This adds to evidence that the disorder originates in prenatal development. By contrast, he and his colleagues are examining evidence that genetic variation implicated in affective disorders may be associated with transcripts expressed later in life. They are also extending their database to include all transcripts of all the genes in the human genome, examining 1000 post-mortem brains, including many of people who had schizophrenia or other brain disorders.

Multiple brain regions

Sestan and colleagues characterized gene expression in 16 brain regions, including 11 areas of the neocortex, from both hemispheres of 57 human brains that spanned from 40 days post-conception to 82 years – analyzing the transcriptomes of 1,340 samples. Using 1.4 million probes, the researchers measured the expression of exons, which combine to form a gene’s protein product. This allowed them to pinpoint changes in these combinations that make up a protein, as well as to chart the gene’s overall expression.

Among key findings:
Over 90 percent of the genes expressed in the brain are differentially regulated across brain regions and/or over developmental time periods. There are also widespread differences across region and time periods in the combination of a gene’s exons that are expressed.

Timing and location are far more influential in regulating gene expression than gender, ethnicity or individual variation.

Among 29 modules of co-expressed genes identified, each had distinct expression patterns and represented different biological processes. Genetic variation in some of the most well-connected genes in these modules, called hub genes, has previously been linked to mental disorders, including schizophrenia and depression.

Telltale similarities in expression profiles with genes previously implicated in schizophrenia and autism are providing leads to discovery of other genes potentially involved in those disorders.

Sex differences in the risk for certain mental disorders may be traceable to transcriptional mechanisms. More than three-fourths of 159 genes expressed differentially between the sexes were male-biased, most prenatally. Some genes found to have such sex-biased expression had previously been associated with disorders that affect males more than females, such as schizophrenia, Williams syndrome, and autism.


The Sestan study was also funded by NIH’s National Institute on Child Health and Human Development, National Institute on Neurological Disorders and Stroke, and National Institute on Drug Abuse. Data for the Sestan study are posted at www.humanbraintranscriptome.org and at http://www.developinghumanbrain.org, as part of a larger ongoing study, BrainSpan, funded by NIMH under the American Recovery and Reinvestment Act to create an Atlas of Human Brain Development.

The Kleinman study data on genetic variability are accessible to qualified researchers at http://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/study.cgi?study_id=phs000417.v1.p1, while the gene expression data can be found at http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc5GSE30272. In addition, BrainCloud, a web browser application developed by NIMH to interrogate the Kleinman study data, can be downloaded at http://www.libd.org/braincloud.


Our brains are all made of the same stuff. Despite individual and ethnic genetic diversity, our prefrontal cortex shows a consistent molecular architecture. For example, overall differences in the genetic code (“genetic distance”) between African -Americans (AA) and caucasians (cauc) showed no effect on their overall difference in expressed transcripts (“transcriptional distance”). The vertical span of color-coded areas is about the same, indicating that our brains all share the same tissue at a molecular level, despite distinct DNA differences on the horizontal axis. Each dot represents a comparison between two individuals. The AA::AA comparisons (blue) generally show more genetic diversity than cauc::cauc comparisons (yellow), because caucasians are descended from a relatively small subset of ancestors who migrated from Africa, while African Americans are descended from a more diverse gene pool among the much larger population that remained in Africa. AA::cauc comparisons (green) differed most across their genomes as a whole, but this had no effect on their transcriptomes as a whole.
Source: Joel Kleinman, M.D., Ph.D., NIMH Clinical Brain Disorders Branch


Individual genetic variation likely affects the expression of genes. For example, across all ages and ethnicities studied, expression of a gene called ZSWIM7 stays low, medium or high in the prefrontal cortex, depending on which of three versions (A/A, A/G, G/G) is inherited. The versions are created by a tiny variation in the letters of the genetic code (DNA) at a location in the gene called rs1045599.
Source: Joel Kleinman, M.D., Ph.D., NIMH Clinical Brain Disorders Branch


Overall gene expression plummets 5-fold in infancy and 90-fold in childhood from its prenatal peak. The decline levels-off during the middle years, but expression surges again in the last decades of life, as the brain ages. Note: The fetal/infant graph at left is based on a different scale than the lifespan graph at right, so the two are not visually comparable.
Source: Joel Kleinman, M.D., Ph.D., NIMH Clinical Brain Disorders Branch


Males show more sex-biased gene expression. More genes differentially expressed (DEX) between the sexes were found in males than females, especially prenatally. Some genes found to have such sex-biased expression had previously been associated with disorders that affect males more than females, such as schizophrenia, Williams syndrome, and autism. Eleven of the brain areas shown are in the neocortex (NCX), or outer mantle.
Source: Nenad Sestan, M.D., Ph.D., Yale University Department of Neurobiology and Kavli Institute for Neuroscience


Profiling developmental processes. The expression data can be used to create trajectories for the expression of genes involved in particular processes, such as the development of synapses (structures that underlie communication between neurons). These expression trajectories can be compared for different regions, such as the NCX and cerebellar cortex (CBC).
Source: Nenad Sestan, M.D., Ph.D., Yale University Department of Neurobiology and Kavli Institute for Neuroscience

References

Colantuoni c, Lipska BK, Ye T, Hyde TM, Tao R, Leek JT, Colantuoni EA, Elkahloun AG, Herman MM, Weinberger DR, Kleinman JE. Temporal Dynamics and Genetic Control of Transcription in the human prefrontal cortex. Nature 2011. Oct 27

Kang HJ, Kawasawa1YI, Cheng F, Zhu Y, Xu X, Li M, Sousa1 AMM, Pletikos M, Meyer KA, Sedmak G, Guennel G, Shin Y, Johnson MB, Krsnik Z, Fertuzinhos MS, Umlauf S, Lisgo SN, Vortmeyer A, Weinberger DR, Mane S, Hyde TM, Huttner A, Reimers M, Kleinman JE, Šestan N. Spatiotemporal transcriptome of the human brain. Nature 2011. Oct 27.

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The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

The National Institute on Drug Abuse is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world's research on the health aspects of drug abuse and addiction. The Institute carries out a large variety of programs to inform policy and improve practice. Fact sheets on the health effects of drugs of abuse and information on NIDA research and other activities can be found on the NIDA home page at www.drugabuse.gov. To order publications in English or Spanish, call NIDA's new DrugPubs research dissemination center at 1-877-NIDA-NIH or 240-645-0228 (TDD) or fax or email requests to 240-645-0227 or drugpubs@nida.nih.gov. Online ordering is available at http://drugpubs.drugabuse.gov. NIDA's new media guide can be found at http://drugabuse.gov/mediaguide/.

NINDS is the nation's leading funder of research on the brain and nervous system. The NINDS mission is to reduce the burden of neurological disease — a burden borne by every age group, by every segment of society, by people all over the world.

About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s Web site at http://www.nichd.nih.gov/.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

The activities described in this release are funded in part through the American Recovery and Reinvestment Act. More information about NIH's Recovery Act grant funding opportunities can be found at http://grants.nih.gov/recovery/. To track the progress of HHS activities funded through the Recovery Act, visit www.hhs.gov/recovery. To track all federal funds provided through the Recovery Act, visit www.recovery.gov.

Perinatal antidepressant stunts brain development in rats

Miswired brain circuitry traced to early exposure – NIH-funded study

Rats exposed to an antidepressant just before and after birth showed substantial brain abnormalities and behaviors, in a study funded by the National Institutes of Health.

After receiving citalopram, a serotonin-selective reuptake inhibitor (SSRI), during this critical period, long-distance connections between the two hemispheres of the brain showed stunted growth and degeneration. The animals also became excessively fearful when faced with new situations and failed to play normally with peers – behaviors reminiscent of novelty avoidance and social impairments seen in autism. The abnormalities were more pronounced in male than female rats, just as autism affects 3-4 times more boys than girls.

“Our findings underscore the importance of balanced serotonin levels – not too high or low -- for proper brain maturation,” explained Rick Lin, Ph.D., of the University of Mississippi Medical Center, Jackson, a Eureka Award grantee of the NIH’s National Institute of Mental Health.

Lin and colleagues report on their discovery online during the week of Oct. 24, 2011, in the Proceedings of the National Academy of Sciences.

Last July, a study reported an association between mothers taking antidepressants and increased autism risk in their children. It found that children of mothers who took SSRI’s during the year prior to giving birth ran twice the normal risk of developing autism – with treatment during the first trimester of pregnancy showing the strongest effect. A study published last month linked the duration of a pregnant mother’s exposure to SSRIs to modest lags in coordination of movement – but within the normal range – in their newborns counselor ceus

“While one must always be cautious extrapolating from medication effects in rats to medication effects in people, these new results suggest an opportunity to study the mechanisms by which antidepressants influence brain and behavioral development,” said NIMH Director Thomas R. Insel, M.D. “These studies will help to balance the mental health needs of pregnant mothers with possible increased risk to their offspring.”

Earlier studies had hinted that serotonin plays an important role in shaping the still-forming brain in the days just after a rat is born, which corresponds to the end of the third trimester of fetal development in humans. Experimental manipulations of the chemical messenger during this period interfered with formation of sensory-processing regions of the cortex, or outer mantle, and triggered aggressive and anxiety-related behaviors in rodents.

There is also recent evidence in humans that serotonin from the placenta helps shape development of the fetal brain early in pregnancy. Disrupted serotonin has been linked to mood and anxiety disorders. SSRIs, the mainstay medication treatment for these disorders, boost serotonin activity.

Lin and colleagues gave citalopram to male and female rat pups prenatally and postnatally and examined their brains and behavior as they grew up. Male, but not female, SSRI exposed rat pups abnormally froze when they heard an unfamiliar tone and balked at exploring their environment in the presence of unfamiliar objects or scents. These behaviors persisted into adulthood. The male pups especially also shunned normal juvenile play behavior – mimicking traits often seen in children with autism.

A key brain serotonin circuit, the raphe system, known to shape the developing brain during the critical period when the animals were exposed to the drug, showed dramatic reductions in density of neuronal fibers. Evidence of stunted development in the circuit coursed through much of the cortex and other regions important for thinking and emotion, such as the hippocampus.

The researchers also discovered miswiring in the structure responsible for communications between the brain’s left and right hemispheres, called the corpus collosum. Extensions of neurons, called axons, through which such long-distance communications are conducted, were deformed. A protective sheath, called myelin, that normally wraps and boosts axons’ efficiency-- like insulation on an electrical wire – was reduced by one-third in the treated animals. This damage was three times worse in male than in female pups and would likely result in abnormal communication between the two hemispheres, say the researchers.

Moreover, the perinatally exposed animals showed evidence of neurons firing out of sync and other electrophysiological abnormalities, suggesting faulty organization of neuronal networks in the cortex.

The research also was supported by the NIH’s National Center for Research Resources, National Institute of Neurological Disorders and Stroke and National Institute of Child Health and Human Development.


Cross-sections of the part of the rat brain that connects the left and right hemisphere (corpus collosum) show stunted development of neuronal wiring, called axons, in an animal that received an antidepressant (right) during a critical period around the time of birth. A protective sheath, called myelin (visible in normal animal at left), that normally wraps the axons and boosts their efficiency, failed to develop normally in the treated animal. The resultant inefficient neuronal communications could underlie the pattern of deficits seen in autism.
Source: Rick C.S. Lin, Ph.D., University of Mississippi Medical Center

Reference

Perinatal antidepressant exposure alters cortical network function in rodents. Simpson KL, Weaver KJ, de Villers-Sidani E, Lu JY-F, Cai Z, Pang Y, Rodriguez-Porcel F, Paul IA, Merzenich M, Lin RCS. 2011, Oct. 24, PNAS.

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The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

The National Center for Research Resources (NCRR), a part of NIH, provides laboratory scientists and clinical researchers with the resources and training they need to understand, detect, treat and prevent a wide range of diseases. NCRR supports all aspects of translational and clinical research, connecting researchers, patients and communities across the nation. For more information, visit www.ncrr.nih.gov. NINDS is the nation's leading funder of research on the brain and nervous system. The NINDS mission is to reduce the burden of neurological disease — a burden borne by every age group, by every segment of society, by people all over the world.

About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s Web site at http://www.nichd.nih.gov/.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Continued Use of Stimulants for ADHD Likely Does Not Increase Risk for Hypertension, but May Affect Heart Rate

Source: NIMH

Chronic use of stimulant medication to treat attention deficit hyperactivity disorder (ADHD) in children does not appear to increase risk for high blood pressure over the long term, but it may have modest effects on heart rate, according to follow-up data from the NIMH-funded Multimodal Treatment Study of Children with ADHD (MTA). The study was published online ahead of print Sept 2, 2011, in the American Journal of Psychiatry continuing education for counselors

Background

The MTA was the first major multi-site trial comparing different treatments for ADHD in childhood. The initial results of the 14-month study, in which 579 children were randomly assigned to one of three intensive treatment groups (medication management alone, behavioral treatment alone, a combination of both) or to routine community care, were published in 1999. The researchers found that medication management alone or in combination with behavioral therapy produced better symptomatic relief for children with ADHD than just behavioral therapy or usual community care.

After the study ended, participants returned to community treatment and were free to pursue whatever treatment course they wished. MTA researchers gathered follow-up data from MTA study participants at 2, 3, 6, 8, and 10 years after study entry.

ADHD is often a chronic condition that continues into adolescence, so some children take stimulants for years. Because stimulants can affect the heart, doctors are concerned about the possible risks for rapid heart rate, hypertension (high blood pressure) or other cardiovascular effects after many years of use. But studies have been inconsistent about whether the effects are long-lasting.

For this most recent data analysis, Benedetto Vitiello, M.D., of NIMH, and MTA colleagues examined the MTA follow-up data to determine if there was an association between chronic use of stimulant medication and changes in blood pressure or heart rate over a 10-year period.

Results of the Study

At the end of the 14-month study, children who were randomized to stimulant treatment in the study had, on average, higher heart rates compared to the children who were randomized to non-medication or community care. Heart rates for the children who continued to take stimulants after the end of the study were slightly elevated at subsequent checks, but they did not have an abnormally elevated heart rate (e.g., tachycardia).

The researchers concluded that stimulant medication did not appear to increase the risk for abnormal elevations in blood pressure or heart rate over a 10-year period. However, because some epidemiological studies have indicated that even modest elevations in heart rate may increase a person’s lifetime risk for cardiovascular problems, the persistent effect of continuous stimulant treatment on heart rate should not be dismissed.

Significance

The results of this study indicate that the effect of stimulants on heart rate can be detected even after years of use, suggesting that the body does not get completely used to it. However, after 10 years of treatment, researchers found no increased risk for hypertension. In addition, none of the children reported any adverse cardiovascular events over the 10-year period.

The researchers do note that the effect on heart rate may be clinically significant for individuals who have underlying heart conditions. Therefore, children taking stimulants over the long-term should be monitored regularly for potential cardiovascular complications.

Citation

Vitiello B, Elliott GR, Swanson JM, Arnold E, Hechtman L, Abikoff H, Molina BSG, Wells K, Wigal T, Jensen PS, Greenhill LL, Kaltman JR, Severe JB, Odbert C, Hur K, Gibbons R. Blood pressure and heart rate in the multimodal treatment of attention deficit/hyperactivity disorder study over 10 years. American Journal of Psychiatry. Online ahead of print Sept 2, 2011.

Novel Model of Depression from Social Defeat Shows Restorative Power of Exercise

New Neurons Pinpointed as Central to Exercise Benefit

In a study in a mouse model that mimics the contribution of social stress to human depression, an environment that promotes exercise and exploration alleviated depressive behavior in the mice. The beneficial effect of activity depended on the growth of new neurons in the adult brain Continuing Education for Counselors

Background
In the 1990s scientists established that new neurons grow in the adult as well as the immature brain. The functions of neurogenesis, or new neuronal growth, are still being explored, but it is known that stress slows this growth in the hippocampus―a brain center involved in the formation of new memories―and that antidepressant treatment promotes it.

Previous research in animal models has also demonstrated that environmental enrichment―the addition of features in an animal's cage that provide opportunities for exercise and investigation―fosters resilience to stress and can alleviate the depression-like behavior that results from uncontrollable stress. Environmental enrichment has also been shown to promote hippocampal neurogenesis in animals.

This Study
This work, by Michael Lehmann and Robert Schloesser and colleagues in NIMH's intramural research program, focused on the ability of environmental enrichment to reverse depressive behaviors caused by social defeat, a situation paralleling the social stresses that can trigger human depression. Past work in animal models has often used physical stressors such as electric shock, restraint, or forced exercise to create depressive behaviors. In addition, the scientists inserted a gene in mice that made it possible to selectively interrupt the growth of new neurons at a specific time and in a specific population of cells in the hippocampus, avoiding any spillover effects to other tissues.

More on Mouse Behavior
Although "dominant and aggressive" may not sound like descriptors that apply to mice, male mice in the wild live apart from other males and they are intensely aggressive if housed together. In this study, male mice were allowed to interact directly for no more than five minutes at a time and were supervised to make sure one mouse did not injure or kill the other.
Mice naturally cover territory in the wild; if furnished with running wheels in a cage, they will, on their own, run the equivalent of as much as 6 to 10 kilometers in one day.
Stress―in this case social defeat stress―has unmistakable effects on the behavior of mice. Researchers use a variety of tests to describe changes in behavioral tendencies, including observing how boldly the mice explore an unfamiliar cage; how much time they will choose to spend in a dark (safe) vs. light (risky) compartment; and the extent to which they'll indulge their taste for something pleasant like sweetened water. Mice who have been the losers of repeated social defeats are visibly cautious and subdued, even in the judgment of observers who do not know whether they were winners or losers in a conflict.
Test mice in this study were housed across a partition in the home cage of a dominant, aggressor mouse. For 5 minutes per day, the partition was removed, allowing the "intruder" and dominant mouse to interact directly. After 2 weeks, the test mice consistently behaved submissively. The test mice were then divided and placed in either a spare environment, or one enriched with running wheels, and tubes of various shapes and sizes. Some of the mice assigned to either environment were a standard laboratory strain. Others had an inserted gene targeted to a population of hippocampal cells that give rise to new neurons; in mice with this transgene, the antibiotic valganciclovir is toxic to dividing cells so neurogenesis is prevented when the drug was added to the animals' feed.

The nontransgenic test mice in the enriched environment, but not those in the more spartan cages, recovered from the submissive behavior seen after social defeat. The transgenic mice, in which neurogenesis was stopped, remained submissive, resembling the mice housed in the impoverished environment.

In tests to probe affect, or mood, the transgenic mice housed in the enriched environment also resembled mice housed in the impoverished environment in that they showed the same reduced inclination to explore, greater anxiety, and a less than normal interest in sweet solutions which mice usually prefer. Interruption of neurogenesis had no effects on the baseline health and behavior of the animals, so the lack of new neurons did not cause depression, but interfered with recovery.

Significance
This study demonstrates that psychosocial stress in mice can cause behavior resembling human depression, which environmental enrichment can ameliorate as long as neurogenesis is intact.

Key elements of this study included its use of a social stressor, more analogous to the social experiences that can contribute to human depression than the physical stressors often used in research. In addition, the use of the transgene in test animals enabled the scientists to control the interruption of neurogenesis with precision with respect to both timing and location and with no effects on neighboring cells.

According to author Michael Lehmann, "There are multiple avenues through which environmental enrichment can have a positive impact on depression. In this model we use a natural psychosocial stressor with relevance to social stress in humans, to induce depressive-like behaviors. We show that environmental enrichment can facilitate the recovery from social stress, and that adult neurogenesis is a requirement for the rehabilitating effects of enrichment."

The authors suggest that neurogenesis may be central to the ability of an animal to update emotional information upon exposure to a novel environment. With neurogenesis impaired, they may be unable to integrate information on the features of a new, changed environment. The resulting cognitive distortions may trigger symptoms of major depression.

Research suggests that one important consequence of environmental enrichment is its impact on the function of the body's stress response system. Animals in these enriched environments show positive effects on the physiology of stress resilience. In humans, successful antidepressant treatment is reflected in similar beneficial changes. Prior research has also linked neurogenesis with positive changes in the stress response system.

The authors also point out that in humans, physical exercise and positive psychosocial activity have beneficial effects on depression and stress resilience. Forms of entertainment that encourage mental activity, according to Lehmann, such as reading, video games, exercise and outdoor recreation could have longer lasting changes for many suffering from mild depressive symptoms than pharmacologic treatment, without the accompanying side effects.

Reference
Schloesser, R.J., Lehmann, M., Martinowich, K., Manji, H.K., and Herkenham, M. Environmental enrichment requires adult neurogenesis to facilitate recovery from psychosocial stress. Molecular Psychiatry 2010 Dec;15(12):1152-1163. Epub 2010 March 23.

Get Fit and Be Active Your Way: Popular New Year's Resolutions

Be Active Your Way
A Guide for Adults

•Wondering about how much activity you need each week?
•Want to get physically active but not sure where to begin?
•Already started a program and would like tips on how to keep it up or step it up?

Written for men and women ages 18 to 64, this booklet is based on the 2008 Physical Activity Guidelines for Americans released by the U.S. Department of Health and Human Services. When reading, you'll want to pay special attention to the Advice to Follow boxes in this booklet. They offer you a quick snapshot of the latest information from these new guidelines.

Share this booklet with your family and friends so you can be active together!

What is physical activity?
Did you know?

•Some activity is better than none.
•The more you do, the greater the health benefits and the better you’ll feel.
Physical activity is any form of exercise or movement of the body that uses energy. Some of your daily life activities—doing active chores around the house, yard work, walking the dog—are examples.

To get the health benefits of physical activity, include activities that make you breathe harder and make your heart and blood vessels healthier. These aerobic activities include things like brisk walking, running, dancing, swimming, and playing basketball. Also include strengthening activities to make your muscles stronger, like push-ups and lifting weights.

The good news?
People of all types, shapes, sizes, and abilities can benefit from being physically active. If you have a disability, choose activities in this booklet that work for you. Talk with your health care team about the amount and types of activities that are right for your ability or condition.

Making Physical Activity a Part of Your Life

Doing More
"I started taking a 45-minute water aerobics class with a group of women from church. It's really a lot of fun, and I am getting in shape. I started out going 2 days a week, and now my goal is to make it to all 3 classes a week."
Congratulations! You are doing some regular physical activity each week and are ready to do more. You may be feeling the benefits of getting active, such as having fun with friends, sleeping better, and getting toned. Are you looking for ways to do more activities at a moderate level?

Here are 2 examples for adding more activity
1.You can do more by being active longer each time. Walking for 30 minutes, 3 times a week? Go longer—walk for 50 minutes, 3 times a week.
2.You can do more, by being active more often. Are you biking lightly 3 days a week for 25 minutes each time? Increase the number of days you bike. Work up to riding 6 days a week for 25 minutes each time.
Tip: If you have not been this active in the past, work your way up. In time, replace some moderate activities with vigorous activities that take more effort. These are explained in detail in Part 3. Counselor Continuig Education
Activities for stronger muscles and bones
Advice to follow:
Adults should do activities to strengthen muscles and bones at least 2 days a week.
Choose activities that work all the different parts of the body—your legs, hips, back, chest, stomach, shoulders, and arms. Exercises for each muscle group should be repeated 8 to 12 times per session.

Try some of these activities a couple of days a week:
•Heavy gardening (digging, shoveling)
•Lifting weights
•Push-ups on the floor or against the wall
•Sit-ups
•Working with resistance bands (long, wide rubber strips that stretch)
Tip: Some people like resistance bands because they find them easy to use and put away when they are done. Others prefer weights; you can use common grocery items, such as bags of rice, vegetable or soup cans, or bottled water.

For best success
•Team up with a friend. It will keep you motivated and be more fun.
•Pick activities that you like to do.
•Track your time and progress. It helps you stay on course. Fill in these forms to help set your activity goals. Before you know it, you'll be able to do at least 2 hours and 30 minutes of activities at a moderate level each week.
•Add in more strength-building activities over time. For example, you can do sit-ups or push-ups.

Shaping up
"My son and I play in a baseball league twice a week. On the days we play, I sleep much better at night. This makes me want to do more on other days. My son wants to lift weights together, and so we got some weights and work out in the basement."

Planning your activity for the week
Physical activity experts say that spreading aerobic activity out over at least 3 days a week is best. Also, do each activity for at least 10 minutes at a time. There are many ways to fit in 2 hours and 30 minutes a week. For example, you can do 30 minutes of aerobic activity each day, for 5 days.

On the other 2 days, do activities to keep your muscles strong. Find ways that work well for you.

Want to learn more about how to add physical activity to your life?
•Join a fitness group.
•Talk to your health care provider about good activities to try.
•Speak to the worksite wellness coordinator at your job.
•Visit www.healthfinder.gov and type "activity" in the search box.

Resilience

What Is Resilience?

Resilience is the ability to:
Bounce back
Take on difficult challenges and still find meaning in life
Respond positively to difficult situations
Rise above adversity
Cope when things look bleak
Tap into hope
Transform unfavorable situations into wisdom, insight, and compassion
Endure

Resilience refers to the ability of an individual, family, organization, or community to cope with adversity and adapt to challenges or change. It is an ongoing process that requires time and effort and engages people in taking a number of steps to enhance their response to adverse circumstances. Resilience implies that after an event, a person or community may not only be able to cope and recover, but also change to reflect different priorities arising from the experience and prepare for the next stressful situation.

Resilience is the most important defense people have against stress.
It is important to build and foster resilience to be ready for future challenges.
Resilience will enable the development of a reservoir of internal resources to draw upon during stressful situations.
Research (Aguirre, 2007; American Psychological Association, 2006; Bonanno, 2004) has shown that resilience is ordinary, not extraordinary, and that people regularly demonstrate being resilient.

Resilience is not a trait that people either have or do not have.
Resilience involves behaviors, thoughts, and actions that can be learned and developed in anyone.
Resilience is tremendously influenced by a person's environment.
Resilience changes over time. It fluctuates depending on how much a person nurtures internal resources or coping strategies. Some people are more resilient in work life, while others exhibit more resilience in their personal relationships. People can build resilience and promote the foundations of resilience in any aspect of life they choose.

What Is Individual or Personal Resilience?
Individual resilience is a person's ability to positively cope after failures, setbacks, and losses. Developing resilience is a personal journey. Individuals do not react the same way to traumatic or stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies to build their resilience. Because resilience can be learned, it can be strengthened. Personal resilience is related to many factors including individual health and well-being, individual aspects, life history and experience, and social support.

Individual Health and Well-Being Individual Aspects Life History and Experience Social Support These are factors with which a person is born.

Personality
Ethnicity
Cultural background
Economic background

These are past events and relationships that influence how people approach current stressors:
Family history
Previous physical health
Previous mental health
Trauma history
Past social experiences
Past cultural experiences

These are support systems provided by family, friends, and members of the community, work, or school environments:
Feeling connected to others
A sense of security
Feeling connected to resources
(Adapted from Simon, Murphy, & Smith, 2008)


Along with the factors listed above, there are several attributes that have been correlated with building and promoting resilience.

The American Psychological Association reports the following attributes regarding resilience:
The capacity to make and carry out realistic plans
Communication and problem-solving skills
A positive or optimistic view of life
Confidence in personal strengths and abilities
The capacity to manage strong feelings, emotions, and impulses

What Is Family Resilience?
Family resilience is the coping process in the family as a functional unit. Crisis events and persistent stressors affect the whole family, posing risks not only for individual dysfunction, but also for relational conflict and family breakdown. Family processes mediate the impact of stress for all of its members and relationships, and the protective processes in place foster resilience by buffering stress and facilitating adaptation to current and future events. Following are the three key factors in family resilience (Wilson & Ferch, 2005):

Family belief systems foster resilience by making meaning in adversity, creating a sense of coherence, and providing a positive outlook.
Family organization promotes resilience by facilitating flexibility, capacity to adapt, connectedness and cohesion, emotional and structural bonding, and accessibility to resources.
Family communication enhances resilience by engaging clear communication, open and emotional expressions, trust and collaborative problem solving, and conflict management.

What Is Organizational Resilience?
Organizational resilience is the ability and capacity of a workplace to withstand potential significant economic times, systemic risk, or systemic disruptions by adapting, recovering, or resisting being affected and resuming core operations or continuing to provide an acceptable level of functioning and structure.

A resilient workforce and organization is important during major decisions or business changes.
Companies and organizations, like individuals, need to be able to rebound from potentially disastrous changes.
The challenge for the incorporation of resilience into a workplace is to identify what enhances the ability of an organization to rebound effectively.
Measuring workplace resilience involves identifying and evaluating the following:
Past and present mitigative mechanisms and practices that increase safety
Past and present mitigative mechanisms and practices that decrease error
Necessary redundancy in systems
Planning and programming that demonstrate collective mindfulness
Anticipation of potential trouble and solutions to potential problems

What Is Community Resilience?
Community resilience is the individual and collective capacity to respond to adversity and change. It is a community that takes intentional action to enhance the personal and collective capacity of its citizens and institutions to respond to and influence the course of social and economic change. For a community to be resilient, its members must put into practice early and effective actions so that they can respond to change. When responding to stressful events, a resilient community will be able to strengthen community bonds, resources, and the capacity to cope. Systems involved with building and maintaining community resilience must work together.
mental health and social work ceus

How Does Culture Influence Resilience?
Cultural resilience refers to a culture’s capacity to maintain and develop cultural identity and critical cultural knowledge and practices. Along with an entire culture fostering resilience, the interaction of culture and resilience for an individual also is important. An individual’s culture will have an impact on how the person communicates feelings and copes with adversity. Cultural parameters are often embedded deep in an individual. A person’s cultural background may influence one deeply in how one responds to different stressors. Assimilation could be a factor in cultural resilience, as it could be a positive way for a person to manage his/her environment. However, assimilation could create conflict between generations, so it could be seen as positive or negative depending on the individual and culture. Because of this, coping strategies are going to be different. With growing cultural diversity, the public has greater access to a number of different approaches to building resilience. It is something that can be built using approaches that make sense within each culture and tailored to each individual.

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What Factors Promote Resilience?
Resilience involves the modification of a person's response to a potentially risky situation. People who are resilient are able to maintain high self-esteem and self-efficacy in spite of the challenges they face. By fostering resilience, people are building psychological defenses against stress. The more resources and defenses available during a time of struggle, the better able to cope and bounce back from adverse circumstances people will be. A person’s ability to regain a sense of normalcy or define a new normalcy after adverse circumstances will be partially based on the resources available to him/her. Resilience building can begin at any time. Following is information regarding applicable ways to implement resilience practices, as well as situations that could inhibit resilience, situations that enhance resilience, and people who help facilitate the growth of resilience.

Resilience


Demonstrating Resilience Vulnerability Factors Inhibiting Resilience Protective Factors Enhancing Resilience Facilitators of Resilience
Individual Resilience
The ability for an individual to cope with adversity and change
Optimism
Flexibility
Self-confidence
Competence
Insightfulness
Perseverance
Perspective
Self-control
Sociability
Poor social skills
Poor problem solving
Lack of empathy
Family violence
Abuse or neglect
Divorce or partner breakup
Death or loss
Lack of social support
Social competence
Problem-solving skills
Good coping skills
Empathy
Secure or stable family
Supportive relationships
Intellectual abilities
Self-efficacy
Communication skills

Individuals
Parents
Grandparents
Caregivers
Children
Adolescents
Friends
Partners
Spouses
Teachers
Faith Community

Organizational Resilience
The ability for a business or industry, including its employees, to cope with adversity and change
Proactive employees
Clear mission, goals, and values
Encourages opportunities to influence change
Clear communication
Nonjudgmental
Emphasizes learning
Rewards high performance
Unclear Expectations
Conflicted expectations
Threat to job security
Lack of personal control
Hostile atmosphere
Defensive atmosphere
Unethical environment
Lack of communication

Open communication
Supportive colleagues
Clear responsibilities
Ethical environment
Sense of control
Job security
Supportive management
Connectedness among departments
Recognition

Employers
Managers
Directors
Employees
Employee assistance programs
Other businesses

Community Resilience
The ability for an individual and the collective community to respond to adversity and change.
Connectedness
Commitment to community
Shared values
Structure, roles, and responsibilities exist throughout community
Supportive
Good communication
Resource sharing
Volunteerism
Responsive organizations
Strong schools

Lack of support services
Social discrimination
Cultural discrimination
Norms tolerating violence
Deviant peer group
Low socioeconomic status
Crime rate
Community disorganization
Civil rivalry
Access to Support services
Community networking
Strong cultural identity
Strong social support systems
Norms against violence
Identification as a community
Cohesive community leadership
Community leaders
Faith-based organizations
Volunteers
Nonprofit organizations
Churches/houses of worship
Support services staff
Teachers
Youth groups
Boy/Girl Scouts
Planned social networking events

(Adapted from Kelly, 2007)
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How Is Personal Resilience Built?
Developing resilience is a personal journey. People do not react the same way to traumatic events. Some ways to build resilience include the following actions:

Making connections with others
Looking for opportunities for self-discovery
Nurturing a positive view of self
Accepting that change is a part of living
Taking decisive actions
Learning from the past
The ability to be flexible is a great skill to obtain and facilitates resilience growth. Getting help when it is needed is crucial to building resilience. It is important to try to obtain information on resilience from books or other publications, self-help or support groups, and online resources like the ones found in this resource collection.

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What Can Be Done to Promote Family Resilience?
Developing family resilience, like individual resilience, is different for every family. The important idea to keep in mind is that an underlying stronghold of family resilience is cohesion, a sense of belonging, and communication. It is important for a family to feel that when their world is unstable they have each other. This sense of bonding and trust is what fuels a family's ability to be resilient. Families that learn how to cope with challenges and meet individual needs are more resilient to stress and crisis. Healthy families solve problems with cooperation, creative brainstorming, openness to others, and emphasis on the role of social support and connectedness (versus isolation) in family resiliency. Resilience is exercised when family members demonstrate behaviors such as confidence, hard work, cooperation, and forgiveness. These are factors that help families withstand stressors throughout the family life cycle.

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How Is Community Resilience Fostered?
Fostering community resilience will greatly depend on the community itself and involves the community working as a whole toward preparedness. It is the capacity for the collective to take preemptive action toward preparedness. Community resilience involves the following factors:

Connection and caring
Collective resources
Critical analysis of the community
Skill building for community members
Prevention, preparedness, and response to stressful events
Resilience is exercised when community members demonstrate behaviors such as confidence, hard work, cooperation, and resourcefulness, and support of those who have needs during particular events. These are factors that help communities withstand challenging circumstances. There are other tips about how to foster community resilience in this resource collection.

Developing resilience is a personal journey. All people do not react the same to traumatic and stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies. Resilience involves maintaining flexibility and balance in life during stressful circumstances and traumatic events. Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. Stress can be dealt with proactively by building resilience to prepare for stressful circumstances, while learning how to recognize symptoms of stress. Fostering resilience or the ability to bounce back from a stressful situation is a proactive mechanism to managing stress.

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References
Aguirre, B. (2007). Dialectics of vulnerability and resilience. Georgetown Journal of Poverty Law and Policy, 14(39), 1–18.

American Psychological Association. (2006). The road to resilience. Retrieved March 20, 2009, from " target="_blank">http://www.apahelpcenter.org/featuredtopics/feature.php?id=6.

Bonanno, G. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28.

Kelly, S. (2007). Personal and community resilience: Building it and sustaining it. Retrieved March 23, 2009, from the University of California Los Angeles Bureau for Behavioral Health and Health Facilities at " target="_blank">http://www.wvdhhr.org/healthprep/common/resiliency.ppt#256.

Simon, J., Murphy, J., & Smith, S. (2008). Building resilience: Appreciate the little things in life. British Journal of Social Work, 38, 218–235.

Wilson, S., & Ferch, S. (2005). Enhancing resilience in the workplace through the practice of caring relationships. Organization Development Journal, 23(4), 45–60.

HIV Treatment

According to Stebbing et al. (2008), "preclinical and cohort studies suggest that certain antidepressants are associated with a predisposition to cancer whereas others decrease the risk" (p. 2305). Additionally, "despite extensive data demonstrating that HIV infection and associated immunosuppression predisposes individuals to a wide range of cancers . . . (including non-AIDS-related malignancies . . .), no studies have specifically investigated the association between antidepressant use, length of antidepressant exposure, and the development of both AIDS-related and non-AIDS-related cancers in the highly active antiretroviral therapy (HAART) and pre-HAART eras" (p. 2306).

Stebbing and colleagues therefore set out "to assess whether different classes of antidepressants were associated with changes in cancer incidence in a population of HIV-1 infected individuals, based on duration of exposure" (p. 2305). The investigators found that, within a "cohort of 10,997 patients . . . attending a large HIV center during the pre-HAART and HAART eras, a total of 2,004 (18%) were prescribed antidepressants. . . . A total of 1,607 (15%) individuals were diagnosed with cancer. There were no significant associations between any class of antidepressant and any type of cancer . . . , in either the pre-HAART or HAART era" (p. 2305). Stebbing and colleagues conclude that "antidepressants, irrespective of their class, do not affect cancer risk in HIV-infected individuals" (p. 2305).



Neuropsychological Impairment

In a racially diverse sample of 93 children living with HIV, Hochhauser, Gaur, Marone, and Lewis (2008) "examined the impact of environmental risk factors on the cognitive decline normally observed with pediatric HIV disease progression" (p. 695). The investigators found that "immunosuppression was clearly associated with poorer cognitive outcome in the high-risk children" (p. 695); in other words, there was greater risk for HIV-associated cognitive decline among children living in highly stressful environments. Notably, "this relationship was not seen in those with lower levels of environmental risk" (p. 695). These findings have several implications, according to Hochhauser and colleagues:

First, while medication adherence has been shown to be worse in stressed or disorganized families . . . , it may also be most crucial for those children, as it is they whose neuropsychological functioning is at greatest risk from HIV neurotoxicity. Second, reducing environmental stressors may prove to be neuroprotective. This may be particularly important for patients for whom reducing immunosuppression . . . may be difficult or impossible. In these cases, perhaps their impact on cognitive functioning could be moderated by taking measures to reduce stress. Such interventions might include concrete actions to improve the child's home or family environment . . . or perhaps stress-reduction interventions like psychotherapy or massage therapy. (p. 696)
http://www.aspirace.com/ for lpc continuing education

Adherence to Treatment

Leserman, Ironson, O'Cleirigh, Fordiani, and Balbin (2008) "examine[d] demographic, health behavior and psychosocial correlates (e.g., stressful life events, depressive symptoms) of nonadherence" (p. 403) among 105 men and women residing in South Florida and taking antiretrovirals. Within this sample,

44.8% had missed a medication dose in the past 2 weeks, and 22.1% had missed their medication during the previous weekend. Those with three or more stressful life events in the previous 6 months were 2.5 to more than 3 times as likely to be nonadherent (in the past 2 weeks and previous weekend, respectively) compared to those without such events. Fully 86.7% of those with six or more stresses were nonadherent during the prior 2 weeks compared to 22.2% of those with no stressors. Although alcohol consumption, drug use, and symptoms of depression were related to nonadherence in the bivariate analyses, the effects of these predictors were reduced to nonsignificance by the stressful event measure. (p. 403)

Leserman and colleagues suggest that "having many stressful events may be a more robust correlate of nonadherence than depression. Persons who report more stressful events may have more chaotic lifestyles that may account for their missed medications. . . . These findings suggest that while interventions for depression may be useful, cognitive behavioral interventions that address stress and coping may have a greater impact on adherence to HIV medication" (p. 409).

Malta, Strathdee, Magnanini, and Bastos (2008) conducted a "systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU[s]) and identif[ied] . . . factors associated with non-adherence to HIV treatment" (p. 1242). The investigators selected 41 peer-reviewed studies published between 1996 and 2007; these studies included

a total of 15,194 patients, the majority of whom were HIV-positive DU[s] (n = 11,628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e., Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g.[,] directly observed therapy) and/or drug addiction treatment (especially substitution therapy). (p. 1242)

Malta and colleagues conclude that, although HAART adherence was lower among DUs "than other populations – especially among users of stimulants, incarcerated DU[s,] and patients with psychiatric comorbidities – adherence to HAART among HIV-positive DU[s] can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support" (p. 1242). Moreover, "most papers [included in this review] suggest that the adherence to HAART among HIV-positive [DU]s can be similar to those found among other [people living with HIV/AIDS], once proper timing to initiate treatment is followed, comorbidities are properly managed and treated, psychosocial support is provided, and drug treatment, particularly substitution therapy, is instituted" (p. 1253).

Stress Management

In a departure from the traditional cognitive-behavioral approach to HIV-related stress management (research about which is coincidently and conveniently summarized in the Tool Box in the Summer 2008 issue of mental health AIDS), McCain et al. (2008) conducted a "randomized clinical trial . . . to test effects of three 10-week stress management approaches – cognitive-behavioral relaxation training (RLXN), 4 focused tai chi training (TCHI), 5 and spiritual growth groups (SPRT) 6 – in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection" (p. 431). According to the investigators, the "purpose of the research was to determine whether the three 10-week stress management interventions would improve and sustain improvements 6 months later in the domains of psychosocial functioning, quality of life, and physical health among persons with varying stages of HIV infection. These three outcome domains, along with neuroendocrine and immune mediating variables, were measured by multiple indicators derived from the psychoneuroimmunology (PNI) paradigm" (p. 431). "Interventions were conducted with groups of 6-10 participants who met in suitably equipped conference rooms in an office setting for 90-min sessions weekly for 10 weeks. Participants who attended less than 8 of the 10 intervention sessions were deemed as having incomplete treatments and classified as withdrawn from the study" (p. 433).

McCain and colleagues found that, "in comparison to the CTRL group, both the RLXN and TCHI groups less frequently used emotion-focused coping strategies, and all three intervention groups had higher lymphocyte proliferative function. Generally, decreased emotion-focused coping can be considered an enhancement in coping strategies; however, there was no concurrent increase in problem-focused or appraisal-focused coping, making interpretation of this change more tenuous" (p. 437). Similarly, "the consistent finding of increased lymphocyte proliferation indicates the interventions were associated with enhancement in immune system functional status. . . . However, because there was no significant change in salivary cortisol, the mechanism of increased lymphocyte function is not clear. Ongoing assessment of cytokine activity or patterns of production may ultimately yield insight into other mechanisms involved in immune function changes" (pp. 437-438).

Despite these challenges in interpreting the study findings, McCain and colleagues contend that, in general,

study findings support use of the PNI-based model for stress management in individuals living with HIV infection. Despite modest effects of the interventions on psychosocial functioning in this sample, the robust finding of improved immune function with these stress management approaches has important clinical implications, particularly for persons with immune-mediated illnesses. . . . Findings of this study indicate that immune function and possibly coping and quality of life may be enhanced with cognitive-behavioral stress management, tai chi, and spirituality-based interventions. While further research is needed to examine specific effects of various stress management interventions and to expand the repertoire of alternative approaches that might be effective in enhancing adaptational outcomes, this study contributes to a growing body of well-designed research that generally lends support to the integration of stress management strategies into the standard care of individuals living with HIV infection. (p. 439)

Coping, Social Support, & Quality of Life

Murphy, Greenwell, Resell, Brecht, and Schuster (2008) "investigated current autonomy among early and middle adolescents affected by maternal HIV (N = 108), as well as examined longitudinally the children's responsibility taking when they were younger (age 6-11; N = 81) in response to their mother's illness and their current autonomy as early/middle adolescents" (p. 253). Within this sample of primarily low-income Latino and African American families residing in Los Angeles County, "children with greater attachment to their mothers had higher autonomy [when performing household-centered activities], and there was a trend for children who drink or use drugs alone to have lower autonomy. In analyses of management autonomy[, which encompasses activities performed outside the home], attachment to peers was associated with higher autonomy" (p. 253). In their longitudinal analysis of this cohort, Murphy and colleagues found that "those children who had taken on more responsibility for instrumental caretaking roles directly because of their mother's illness showed better autonomy development as early and middle age adolescents" (p. 253). Importantly, the investigators also found that autonomy was associated "with 'positive' characteristics such a mother-child bond and coping self-efficacy" (p. 271). Murphy and colleagues conclude that

"parentification" of young children with a mother with HIV/AIDS – that is, the young children taking on household responsibilities due to the mother's illness – may not negatively affect later autonomy development in these children. While it may indeed have other detrimental effects, such as more absence from school and school performance . . . , in at least this limited sample of children affected by HIV, higher responsibility taking as a result of maternal HIV/AIDS among young children was associated with later early/middle adolescent higher autonomy functioning. . . . Thus, even if they experienced some distress from parentification at an earlier age, it did not interfere with their long-term early and middle adolescent autonomous functioning. (p. 272)

Murphy and colleagues acknowledge that these findings require additional exploration with larger samples. Nevertheless, the investigators stress that if

HIV-positive mothers, due to their fatigue or illness, must rely on their young children at times to perform behaviors that most children their age do not typically perform, then it is critical that there be a strong focus on the mother developing or maintaining: (1) A high level of attachment and bond between herself and the child; and (2) strong support of the child to assist in the child developing strong coping self-efficacy. . . . [I]f a child does indeed have to sometimes function in a "parentified" role, then the data from this study indicate that children with a close attachment to their mother and who have good coping self-efficacy will have higher autonomy as they develop; these are both issues that can be worked on and improved in family therapy. (p. 272)

With a sample of 104 MSM averaging 50 years of age and living with HIV, Dutch investigators (Kraaij, van der Veek, et al., 2008) assessed relationships among "coping strategies, goal adjustment, and symptoms of depression and anxiety" (p. 395). The investigators found that "cognitive coping strategies had a stronger influence on well-being than . . . behavioral coping strategies: positive refocusing, positive reappraisal, putting into perspective, catastrophizing, and other-blame were all significantly related to symptoms of depression and anxiety. In addition, withdrawing effort and commitment from unattainable goals, and reengaging in alternative meaningful goals, in [the] case that preexisting goals can no longer be reached, seemed to be a fruitful way to cope with being HIV[-]positive" (p. 395). With regard to intervention, as Kraaij and colleagues see it, "the focus of treatment could be the content of thoughts and bringing about effective cognitive change, combined with working on goal adjustment. Various studies showed the positive effects of cognitive-behavioral oriented interventions . . . and coping effectiveness training . . . in improving psychological states in HIV-infected men. Future studies should be undertaken looking at the effectiveness of intervention programs focusing on cognitions and life goals" (p. 400).

In another study by this research group with the same sample of MSM (Kraaij, Garnefski, et al., 2008), the investigators found that greater

use of positive refocusing, refocus[ing] on planning, positive reappraisal, putting into perspective, and less use of other-blame, was related to higher levels of personal growth. . . . [P]ositive reappraisal appears to be the most powerful predictor of personal growth.

Another important predictor . . . was goal self-efficacy. Respondents who reported a higher belief in their ability to adjust their goals when important goals are obstructed by being HIV-positive, reported higher levels of personal growth. (p. 303)

As in the study described above (Kraajj, van der Veek, et al., 2008), Kraajj, Garnefski, and colleagues conclude that cognitive-behavioral oriented interventions and coping effectiveness training "could be offered to improve personal growth. The specific focus of treatment could be then the content of thoughts, combined with working on goal adjustment. Ingredients of treatment should be a combination of (positive) cognitive coping strategies and goal self-efficacy" (p. 303).

---- Compiled by Abraham Feingold, Psy.D.

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4 The structured RLXN training intervention "consisted of physical and mental relaxation skills training, with a focus on individualized combinations of relaxation techniques, as well as active coping strategies for stress management. Participants were expected to routinely practice relaxation techniques during and following the intervention, and daily practice frequency was recorded each week. Each participant was given a set of eight 30-min audiotapes specifically produced for use in this study" (p. 433).

5 A focused short form of TCHI "involving eight movements was developed for this study. The intervention sequence began with a focus on breathing and balance, both key elements in all tai chi exercises. The sequence of movements taught was focused on developing each individual's skills in balancing, focused breathing, gentle physical posturing and movement, and the active use of consciousness for relaxation. Training videotapes were provided to participants for weekly and ongoing practice of the techniques" (p. 434).

6 "The SPRT . . . intervention was designed to facilitate personal exploration of spirituality and to enhance exploration of the spiritual self and awareness of the meaning and expression of spirituality. Each session was designed to explore an aspect of spirituality and included the intellectual process of knowing or apprehending spirituality; the experiential component of interconnecting one's spirit with self, others, nature, God, or a higher power; and an appreciation of the multisensory experience of spirituality. The process of weekly journal entries facilitated increased awareness and the integration of spirituality into daily life" (p. 434).

Getting Through Tough Economic Times

This guide provides practical advice on how to deal with the effects financial difficulties can have on your physical and mental health -- it covers:

•Possible health risks
•Warning signs
•Managing stress
•Getting help
•Suicide warning signs
•Other steps you can take
Possible Health Risks
Economic turmoil (e.g., increased unemployment, foreclosures, loss of investments and other financial distress) can result in a whole host of negative health effects - both physical and mental. It can be particularly devastating to your emotional and mental well-being. Although each of us is affected differently by economic troubles, these problems can add tremendous stress, which in turn can substantially increase the risk for developing such problems as:

•Depression
•Anxiety
•Compulsive Behaviors (over-eating, excessive gambling, spending, etc.)
•Substance Abuse
Warning Signs
It is important to be aware of signs that financial problems may be adversely affecting your emotional or mental well being --or that of someone you care about. These signs include:

•Persistent Sadness/Crying
•Excessive Anxiety
•Lack of Sleep/Constant Fatigue
•Excessive Irritability/Anger
•Increased drinking
•Illicit drug use, including misuse of medications
•Difficulty paying attention or staying focused
•Apathy - not caring about things that are usually important to you
•Not being able to function as well at work, school or home
Managing Stress
If you or someone you care about is experiencing these symptoms, you are not alone. These are common reactions to stress, and there are coping techniques that you can use to help manage it. They include:

•Trying to keep things in perspective - recognize the good aspects of life and retain hope for the future.
•Strengthening connections with family and friends who can provide important emotional support.
•Engaging in activities such as physical exercise, sports or hobbies that can relieve stress and anxiety.
•Developing new employment skills that can provide a practical and highly effective means of coping and directly address financial difficulties.
Getting Help
Even with these coping techniques, however, sometimes these problems can seem overwhelming and you may need additional help to get through "rough patches." Fortunately, there are many people and services that can provide help. These include your:

•Healthcare provider
•Spiritual leader
•School counselor
•Community health clinic
If you need help finding treatment services you can access our Mental Health Services Locator for information and mental health resources near you. Similarly, if you need help with a substance abuse problem you can use our Substance Abuse Treatment Facility Locator.

Specific help for financial hardship is also available, on issues such as:

•Making Home Affordable
•Foreclosure
•Reemployment
•Financial assistance
There are many other places where you can turn for guidance and support in dealing with the financial problems affecting you or someone you care about. These resources exist at the federal, state and community level and can be found through many sources such as:

•Federal and state government
•Civic associations
•Spiritual groups
•Other sources such as the government services section of a phone book
Suicide Warning Signs
Unemployment and other kinds of financial distress do not "cause" suicide directly, but they can be factors that interact dynamically within individuals and affect their risk for suicide. These financial factors can cause strong feelings such as humiliation and despair, which can precipitate suicidal thoughts or actions among those who may already be vulnerable to having these feelings because of life-experiences or underlying mental or emotional conditions (e.g., depression, bi-polar disorder) that place them at greater risk of suicide.

LCSW, MFT, LPC ceus suicide prevention
These are some of the signs you may want to be aware of in trying to determine whether you or someone you care about could be at risk for suicide:

•Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
•Looking for ways to kill oneself
•Thinking or fantasying about suicide
•Acting recklessly
•Seeing no reason for living or having no sense of purpose in life
If you or someone you care about are having suicidal thoughts or showing these symptoms SEEK IMMEDIATE HELP. Contact your healthcare provider, mental health crisis center, hospital emergency room or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for help.

Other Steps You Can Take
•Acknowledge that economic downturns can be frightening to everyone, but that there are ways of getting through them - from engaging in healthy activities, positive thinking, supportive relationships, to seeking help when needed from health professionals.


•Encourage community-based organizations and groups to provide increased levels of mental health treatment and support to those who are severely affected by the economy.


•Work together to help all members of the community build their resiliency and successfully return to healthy and productive lives.
For further information on mental health or substance abuse issues please visit The Substance Abuse and Mental Health Services Administration (SAMHSA).


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Special Note to Journalists
For ideas on how to best cover sensitive issues like suicide prevention in a thoughtful and constructive manner you can check out suggestions developed by the Annenberg Public Policy Center in conjunction with leading suicide prevention experts and journalists.

How to Cheer Yourself Up When Youre Down

Got the colder weather, sour relationshops, no money, poor health, plain ol' down 'n dirty blues? Try some of these strategies to blow away those dark clouds and let the sunshine into your life again.

1) Dance! Put on your favourite music, turn it up loud and dance! This is guaranteed to make you feel good. If you are unable to dance, don't let that stop you having fun - sing at the top of your voice instead.

2) Smile! Force yourself to smile even if you don't feel like it. This tricks your brain into thinking that you are happy. You do want to be happy don't you? Okay then - a great big cheesy grin. After three, one, two, three, - smile :0)

3) Spend time with children. Their natural zest for life is infectious. As well as the pleasures of a spontaneous hug or a chubby little hand in yours, try to take away with you some of their joy in simple things, licking an ice cream, playing with water, tramping through fallen leaves or following a butterfly.

4) Reward yourself. If there is a job that you hate to do, household accounts, home repairs etc. don't keep putting it off so that it is constantly nagging at you. Just get it done. Then reward yourself with whatever you love, a shiny new magazine, a bunch of flowers, a long soak in an aromatic bath, two bars of chocolate or an evening in front of the tv doing absolutely nothing. Or even all of the above if you can afford it. The peace of mind that comes from having got the job done will be the greatest reward of all.

5) Clear out your clutter. The ancient art of Feng Shui believes that getting rid of clutter rids your home or work space of negative stuck energy and allows space for positive energy to surge into all aspects of your life. Whether or not this is correct, it is an undeniable fact that clearing out what you no longer want or need makes life easier. Your home is neater, looks more spacious and is easier to clean. There can also be a tremendous feeling of freedom as you let go of the past and trust in the future to bring you what you will need. Emotional clutter can be even more damaging. We've all said or done things we regret, the trick is to do anything you can to repair the damage and if that is not possible, forgive yourself and toss it out of your life.

6) Take action. If something is worrying you, be it a health problem, or debt or divorce, make that doctor's appointment, get some debt counselling, find out your rights. The reality is often less stressful than sitting alone worrying about it. Try to talk over your problems with a friend, or if that is impossible find a support group on the Internet by typing debt, divorce or whatever into a search engine.

7) Positive thoughts. When you leave the house each morning, say and mean, I'm going to have a great day, it's going to be lots of fun, rather than thinking Oh no, another dreary day at the office to get through. The first attitude will attract good vibrations and positive fun people to you, the second will ensure a depressing day.

8) Have more fun. Apparently children laugh approximately 400 times a day yet adults laugh only about 20 times a day. When do we lose our sense of fun? Claim it back. Play games, watch comedies, have daily jokes delivered to your mailbox or throw a fancy dress party.

9) Make something. Being creative gives you such a buzz you won't stay down in the dumps for long. Stencil a room, make a cake, plan a garden, sketch or paint a picture. Express yourself with a modern collage, change your rooms around, display your collections or start a patchwork quilt.

10) Keep a gratitude journal. Write down half a dozen things every day that you are grateful for, from waking up and seeing your children's beautiful little faces to the smell of the roses in the local park. This cannot fail to cheer you up if you do it regularly as it gives you a whole new way of experiencing your life.

11) Start a new project. Learn a language, trace your family history, redecorate your home, learn to ride a horse, gain a new qualification, take music lessons, learn to make your own soft furnishings or do your own auto repairs. Visualize yourself successfully completing the project and the benefits it will bring to your life. Then make a start and follow it through to the end. An added bonus will be the increased self esteem that comes from having planned, problem solved and perfected the whole project yourself.

12) See your old friends. It's easy to get into a work, family, housework, shopping, sleep and back to work again routine that leaves you no time at all to be the person you once were. The funny, up for a laugh, outgoing young woman you used to be. Spending time with friends who knew the old you seems to resurrect that side of your character. You will come away feeling younger, more positive and more excited by life than you were before you met up. Go on, invite them over to share a pizza and catch up on each other's lives.

13) Paint or accessorize a room that you spend a lot of time in a lovely bright yellow. The colour of sunshine will lift your spirit and bring positive vibrations. We subconciously know about the effects of colour on our emotions which is why we talk about the future looking rosy or having the blues.

14) Take the happiness option. You have the choice whether to spend this day, which you will never live through again, in a state of happiness or unhappiness. Choose to spend it as happily as you possibly can.

Anniversary Reactions to a Traumatic Event

Anniversary Reactions to a Traumatic Event:
The Recovery Process Continues
As the anniversary of a disaster or traumatic event approaches, many survivors report a return of restlessness and fear. Psychological literature calls it the anniversary reaction and defines it as an individual's response to unresolved grief resulting from significant losses. The anniversary reaction can involve several days or even weeks of anxiety, anger, nightmares, flashbacks, depression, or fear.

On a more positive note, the anniversary of a disaster or traumatic event also can provide an opportunity for emotional healing. Individuals can make significant progress in working through the natural grieving process by recognizing, acknowledging, and paying attention to the feelings and issues that surface during their anniversary reaction. These feelings and issues can help individuals develop perspective on the event and figure out where it fits in their hearts, minds, and lives.

It is important to note that not all survivors of a disaster or traumatic event experience an anniversary reaction. Those who do, however, may be troubled because they did not expect and do not understand their reaction. For these individuals, knowing what to expect in advance may be helpful. Common anniversary reactions among survivors of a disaster or traumatic event include:

Memories, Dreams, Thoughts, and Feelings: Individuals may replay memories, thoughts, and feelings about the event, which they can't turn off. They may see repeated images and scenes associated with the trauma or relive the event over and over. They may have recurring dreams or nightmares. These reactions may be as vivid on the anniversary as they were at the actual time of the disaster or traumatic event.
Grief and Sadness: Individuals may experience grief and sadness related to the loss of income, employment, a home, or a loved one. Even people who have moved to new homes often feel a sense of loss on the anniversary. Those who were forced to relocate to another community may experience intense homesickness for their old neighborhoods.
Fear and Anxiety: Fear and anxiety may resurface around the time of the anniversary, leading to jumpiness, startled responses, and vigilance about safety. These feelings may be particularly strong for individuals who are still working through the grieving process.
Frustration, Anger, and Guilt: The anniversary may reawaken frustration and anger about the disaster or traumatic event. Survivors may be reminded of the possessions, homes, or loved ones they lost; the time taken away from their lives; the frustrations with bureaucratic aspects of the recovery process; and the slow process of rebuilding and healing. Individuals may also experience guilt about survival. These feelings may be particularly strong for individuals who are not fully recovered financially and emotionally.
Avoidance: Some survivors try to protect themselves from experiencing an anniversary reaction by avoiding reminders of the event and attempting to treat the anniversary as just an ordinary day. Even for these people, it can be helpful to learn about common reactions that they or their loved ones may encounter, so they are not surprised if reactions occur.
Remembrance: Many survivors welcome the cleansing tears, commemoration, and fellowship that the anniversary of the event offers. They see it as a time to honor the memory of what they have lost. They might light a candle, share favorite memories and stories, or attend a worship service.
Reflection: The reflection brought about by the anniversary of a disaster or traumatic event is often a turning point in the recovery process. It is an opportunity for people to look back over the past year, recognize how far they have come, and give themselves credit for the challenges they surmounted. It is a time for survivors to look inward and to recognize and appreciate the courage, stamina, endurance, and resourcefulness that they and their loved ones showed during the recovery process. It is a time for people to look around and pause to appreciate the family members, friends, and others who supported them through the healing process. It is also a time when most people can look forward with a renewed sense of hope and purpose.
Although these thoughts, feelings, and reactions can be very upsetting, it helps to understand that it is normal to have strong reactions to a disaster or traumatic event and its devastation many months later. Recovery from a disaster or traumatic event takes time, and it requires rebuilding on many levels - physically, emotionally, and spiritually. However, with patience, understanding, and support from family members and friends, you can emerge from a disaster or traumatic event stronger than before.

Stressful Life Events

Stressful Life Events
The most common psychological and social stressors in adult life include the breakup of intimate romantic relationships, death of a family member or friend, economic hardships, racism and discrimination, poor physical health, and accidental and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Although some stressors are so powerful that they would evoke significant emotional distress in most otherwise mentally healthy people, the majority of stressful life events do not invariably trigger mental disorders. Rather, they are more likely to spawn mental disorders in people who are vulnerable biologically, socially, and/or psychologically (Lazarus & Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding variability among individuals to a stressful life event is a major challenge to research. Groups at greater statistical risk include women, young and unmarried people, African Americans, and individuals with lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).

Divorce is a common example. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997).

The death of a child or spouse during early or midadult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.

A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)

More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.

Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).

Past Trauma and Child Sexual Abuse
Severe trauma in childhood may have enduring effects into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and physical abuse, and parental death, divorce, psychopathology, and substance abuse (reviewed in Turner & Lloyd, 1995).

Child sexual abuse is one of the most common stressors, with effects that persist into adulthood. It disproportionately affects females. Although definitions are still evolving, child sexual abuse is often defined as forcible touching of breasts or genitals or forcible intercourse (including anal, oral, or vaginal sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of adults in varying segments of the community have found that 15 to 33 percent of females and 13 to 16 percent of males were sexually abused in childhood (Polusny & Follette, 1995). A recent, large epidemiological study of adults in the general community found a lower prevalence (12.8 percent for females and 4.3 percent for males); however, the definition of sexual abuse was more restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood has a mean age of onset estimated at 7 to 9 years of age (Polusny & Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).

The long-term consequences of past childhood sexual abuse are profound, yet vary in expression. They range from depression and anxiety to problems with social functioning and adult interpersonal relationships (Polusny & Follette, 1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86 percent of adult survivors of child sexual abuse (Polusny & Follette, 1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a specific risk factor for adult-onset depression and twice as many women as men reported a history of abuse. Other long-term effects include self-destructive behavior, social isolation, poor sexual adjustment, substance abuse, and increased risk of revictimization (Browne & Finkelhor, 1986; Briere, 1992).

Very few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials (IOM, 1998). Group therapy and Interpersonal Transaction group therapy were found to be more effective for female survivors than an experimental control condition that offered a less appropriate intervention (Alexander et al., 1989, 1991). In the practice setting, most psychosocial and pharmacological treatments are tailored to the primary diagnosis, which, as noted above, varies widely and may not attend to the special needs of those also reporting abuse history.

Domestic Violence
Domestic violence is a serious and startlingly common public health problem with mental health consequences for victims, who are overwhelmingly female, and for children who witness the violence. Domestic violence (also known as intimate partner violence) features a pattern of physical and sexual abuse, psychological abuse with verbal intimidation, and/or social isolation or deprivation. Estimates are that 8 to 17 percent of women are victimized annually in the United States (Wilt & Olsen, 1996). Pinpointing the prevalence is hindered by variations in the way domestic violence is defined and by problems in detection and underreporting. Women are often fearful that their reporting of domestic violence will precipitate retaliation by the batterer, a fear that is not unwarranted (Sisley et al., 1999).

Victims of domestic violence are at increased risk for mental health problems and disorders as well as physical injury and death. Domestic violence is considered one of the foremost causes of serious injury to women ages 15 to 44, accounting for about 30 percent of all acute injuries to women seen in emergency departments (Wilt & Olsen, 1996). According to the U.S. Department of Justice, females were victims in about 75 percent of the almost 2,000 homicides between intimates in 1996 (cited in Sisley et al., 1999). The mental health consequences of domestic violence include depression, anxiety disorders (e.g., post-traumatic stress disorder), suicide, eating disorders, and substance abuse (IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic violence may suffer acute and long-term emotional disturbances, including nightmares, depression, learning difficulties, and aggressive behavior. Children also become at risk for subsequent use of violence against their dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al., 1999).

Mental health interventions for victims, children, and batterers are highly important. Individual counseling and peer support groups are the interventions most frequently used by battered women. However, there is a lack of carefully controlled, methodologically robust studies of interventions and their outcomes, according to a report by the Institute of Medicine and National Research Council (IOM, 1998). A research agenda for violence against women was developed (IOM, 1996) and has served as an impetus for an ongoing research program sponsored by the U.S. Departments of Justice and Health and Human Services. Clearly, there is an urgent need for development and rigorous evaluation of prevention programs to safeguard against intimate partner violence and its impact on children.

Interventions for Stressful Life Events
Stressful life events, even for those at the peak of mental health, erode quality of life and place people at risk for symptoms and signs of mental disorders. There is an ever-expanding list of formal and informal interventions to aid individuals coping with adversity. Sources of informal interventions include family and friends, education, community services, self-help groups, social support networks, religious and spiritual endeavors, complementary healers, and physical activities. As valuable as these activities may be for promoting mental health, they have received less research attention than have interventions for mental disorders. Nevertheless, there are selected interventions to help people cope with stressors, such as bereavement programs and programs for caregivers (see Chapter 5) as well as couples therapy and physical activity.

Couples therapy is the umbrella term applied to interventions that aid couples in distress. The best studied interventions are behavioral couples therapy, cognitive-behavioral couples therapy, and emotion-focused couples therapy. A recent review article evaluated the body of evidence on the effectiveness of couples therapy and programs to prevent marital discord (Christensen & Heavey, 1999). The review found that about 65 percent of couples in therapy did improve, whereas 35 percent of control couples also improved. Couples therapy ameliorates relationship distress and appears to alleviate depression. The gains from couples therapy generally last through 6 months, but there are few long-term assessments (Christensen & Heavey, 1999). Similarly, interventions to prevent marital discord yield short-term improvements in marital adjustment and stability, but there is insufficient study of long-term outcomes. The prevention programs receiving the most study are the Couple Communication Program, Relationship Enhancement, and the Prevention and Relationship Enhancement Program (Christensen & Heavey, 1999). Greater research is needed to overcome gaps in knowledge and to extend findings to a broader array of programs, to diverse populations of couples, and to a wider set of outcomes, including effects on children.

Physical activities are a means to enhance somatic health as well as to deal with stress. A recent Surgeon General’s Report on Physical Activity and Health evaluated the evidence for physical activities serving to enhance mental health (U.S. Department of Health and Human Services [DHHS], 1996). Aerobic physical activities, such as brisk walking and running, were found to improve mental health for people who report symptoms of anxiety and depression and for those who are diagnosed with some forms of depression. The mental health benefits of physical activity for individuals in relatively good physical and mental health were not as evident, but the studies did not have sufficient rigor from which to draw unequivocal conclusions (DHHS, 1996).

Prevention of Mental Disorders
A promising development in prevention of a specific mental disorder in adults occurred with the publication of results from the San Francisco Depression Research Project (Munoz et al., 1995). This study investigated 150 primary care patients who did not meet diagnostic criteria for depression and who were being seen in a public clinic for other problems. They were randomized to either psychoeducation—an 8-week cognitive behavioral course to help them control and manage moods—or to a control condition. One year later, those who received psychoeducation were found to have developed significantly fewer depression symptoms than members of the control group. This trial is noteworthy in two major respects: it was a randomized controlled trial and its participants were low-income individuals, with high representation of all major minority groups. Low-income individuals are considered a high-risk population because of studies documenting their higher prevalence of mental disorders. This study demonstrated in a methodologically rigorous fashion that depression may be preventable in some cases. It serves as a model for extending the concept of prevention to many mental disorders. Prevention research is vitally important and needs to be enhanced.