Faculty Bibliography

Health information technologies are transforming how mental healthcare is paid for through value-based care programs, which tie payment to data quantifying care outcomes. But, it is unclear what outcomes data these technologies should store, how to engage users in data collection, and how outcomes data can improve care. Given these challenges, we conducted interviews with 30 U.S.-based mental health clinicians to explore the design space of health information technologies that support outcomes data specification, collection, and use in value-based mental healthcare. Our findings center clinicians' perspectives on aligning outcomes data for payment programs and care; opportunities for health technologies and personal devices to improve data collection; and considerations for using outcomes data to hold stakeholders including clinicians, health insurers, and social services financially accountable in value-based mental healthcare. We conclude with implications for future research designing and developing technologies supporting value-based care across stakeholders involved with mental health service delivery.

A long-standing theory for Alzheimer's disease (AD) has been that deterioration of synapses and depressed neuronal activity is a major contributing factor. We review the increasing evidence, in humans and in mouse models, that show that there is often neuronal hyperactivity at early stages rather than decreased activity. We discuss studies in mouse models showing that hyperexcitability can occur long before plaque deposition and memory impairment. In mouse models, a generator of the hyperactivity appears to be the dentate gyrus. We present evidence, based on mouse models, that inhibition of muscarinic cholinergic receptors or medial septal cholinergic neurons can prevent hyperactivity. Therefore, we hypothesize the novel idea that cholinergic neurons are overly active early in the disease, not depressed. In particular we suggest the medial septal cholinergic neurons are overly active and contribute to hyperexcitability. We further hypothesize that the high activity of cholinergic neurons at early ages ultimately leads to their decline in function later in the disease. We review the effects of a prenatal diet that increases choline, the precursor to acetylcholine and modulator of many other functions. In mouse models of AD, maternal choline supplementation (MCS) reduces medial septal cholinergic pathology, amyloid accumulation and hyperexcitability, especially in the dentate gyrus, and improves cognition.

The perinatal period represents a time of profound neurobiological, cognitive, and emotional change. While evidence points to the neuroplasticity of matrescence as adaptive in supporting the transition to motherhood, the perinatal period also entails subjective reports of cognitive difficulty known as "mommy brain" as well as a heightened vulnerability to mental health challenges. The role of cognition in the etiology of postpartum depression is a promising area of investigation into targets for maternal mental health intervention, considering evidence that important cognitive changes occur during the perinatal period, and given that cognitive alterations are key features of mood disorders. Here we review evidence for cognitive plasticity in matrescence, with a particular focus on executive function (EF) given its overlapping significance for adaptation to parenthood, central role in managing the mental load of motherhood, and implications in mood regulation and mood disorders. We also review evidence for EF changes in perinatal depression and major depressive disorder more broadly. Despite the strong association between EF impairments and major depressive disorder, research on EF changes in perinatal depression remains limited. Understanding normative EF changes during this period is essential for better understanding the relationship between EF, perinatal depression, and the mental load of motherhood. Consideration for these cognitive, neurobiological, and psychosocial factors of matrescence is critical for addressing maternal mental health and developing interventions that support parental well-being.

INTRODUCTION/BACKGROUND:During the COVID-19 pandemic, birthing parents were identified as a high-risk group with greater vulnerability to the harms associated with SARS-CoV-2. This led to necessary changes in perinatal health policies but also to experiences of maternal isolation and loneliness, both in hospital settings, due to infection mitigation procedures, and once home, due to social distancing. METHODS:In this study, we qualitatively explored birthing and postpartum experiences in New York City during the early days of the pandemic when lockdowns were in effect and policies and practices were rapidly changing. Using thematic analysis, our focus was on experiences of isolation, navigating these experiences, and the potential impacts of isolation and loneliness on maternal health for 55 birthing people. RESULTS:Participants described numerous stressors related to isolation during the birthing process, including reconciling their hopes for their birth with the realities of the unknown and separation from partners, family, and friends in the hospital. During the postpartum period, loneliness manifested as having limited or no contact with family and friends, which led to feelings of a need for strengthened social support systems. The impact of these negative experiences shaped mental health. Overall, we found that solitary experiences during birthing and postpartum isolation were major sources of stress for participants in this study. DISCUSSION/CONCLUSIONS:To support impacted families and prepare for future crisis events, clinicians and researchers must prioritize the development of strong clinical and social support structures for perinatal people to ensure both maternal and child health.

Toddler visual attention development correlates with subsequent language, cognitive, and social developmental outcomes. This study investigates the association of maternal trauma on toddler looking behaviors in 39 mother-child dyads from the Western Cape Province, South Africa. At 15 months postpartum, maternal trauma was assessed using the Life Events Checklist and toddler multisensory attention skills were measured using the Multisensory Attention Assessment Protocol (MAAP) during eye-tracking. We used two-way mixed ANOVA to analyze the association of maternal trauma and MAAP condition with attention maintenance, intersensory matching, and attention shifting. This study provides support for the MAAP's reliability with a sample of 15-month-old toddlers from a low-income setting. We observed a significant interaction between MAAP condition and maternal trauma group on attention maintenance, but pairwise comparisons did not meet the threshold for statistical significance. In a stratified analysis, toddlers of mothers in the low trauma exposure group demonstrated significant differences in attention maintenance, intersensory matching, and attention shifting by condition. Unexpectedly, toddlers of mothers in the high trauma exposure group did not exhibit significant differences in these attentional skills, potentially indicating attentional adaptations. Further research is needed to explore the relationship between the intergenerational transmission of trauma on infant and toddler multisensory attention skills in low-income settings.

Firesetting behaviors are extremely dangerous not only to the individual but to society as one fire has the potential to destroy property and lead to serious injury or death. Youth firesetting behaviors are often under-assessed in psychiatric care settings intakes due to their relatively low base-rate and only are a part of a practitioner’s conceptualization when these behaviors are part of their presentation to an emergency room. Acute psychiatric care settings are well-equipped to assess and treat many highly dangerous behaviors such as active suicidal and homicidal ideation, as well as non-suicidal self-injury. However, youth firesetting is without a formal and directed plan on how to assess the risk of these behaviors, conceptualize, and intervene effectively. A case study of a 16-year-old multiracial male named “Luis”, who was psychiatrically hospitalized on an adolescent inpatient unit following multiple firesetting behaviors in the community, is used is to show the importance of multiinterdisciplinary collaboration between mental health providers and local fire safety programs. In addition, we will offer several recommendations to providers in the assessment and treatment related to juvenile who fireset

INTRODUCTION/UNASSIGNED:Comorbidity between disorders is pervasive, and its relationship to the main conditions under investigation needs to be addressed for robust causal inference. However, many clinical etiologic studies still fail to capitalize on the theoretical advancements and improved recommendations regarding covariate adjustment in this context. Specifically, studies often lack explicit causal assumptions about the role of comorbidity in exposure-outcome relationships, potentially leading to inappropriate accounting for comorbid conditions and resulting in biased effect estimates. This study aims to explore common causal structures involving comorbidity and provide guidance for handling it in etiologic research. METHODS/UNASSIGNED:We use Directed Acyclic Graphs (DAGs) to depict six causal scenarios involving comorbidity as a confounder, mediator, collider, or consequence of the exposure or outcome, illustrated with real-world clinical examples. Simulations were conducted across 5,000 iterations for each scenario, assessing the impact of conditioning on comorbidity under four effect measures (risk difference, odds ratio, risk ratio, and mean difference). Bias was evaluated by comparing adjusted and unadjusted effect estimates to the true values. RESULTS/UNASSIGNED:The impact of conditioning on comorbidity varied by its causal role. Adjusting for comorbidity mitigated bias when it acted as a confounder but introduced bias when it was a mediator or collider. In instances where comorbidity was a consequence of either the exposure or outcome, the decision to adjust depended on the research objectives and could vary across effect measures. DISCUSSION/UNASSIGNED:Explicit causal assumptions are essential for selecting appropriate analytical strategies in etiologic research. This study provides practical guidance on analytical handling of the measures of comorbidity, highlighting the need for study design and analysis to align with research objectives. Future work should address more complex causal structures and other methodological challenges.

INTRODUCTION/BACKGROUND:Maternal undernutrition and inflammation in utero may significantly impact the neurodevelopmental potential of offspring. However, few studies have investigated the effects of pregnancy interventions on long-term child growth and development. This study will examine the effects of prenatal nutrition and infection management interventions on long-term growth and neurodevelopmental outcomes of offspring. METHODS:The Enhancing Nutrition and Antenatal Infection Treatment ('ENAT') study (ISRCTN15116516) was a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. The study enrolled 2399 pregnant women who were randomised to receive routine care, an enhanced nutrition package (iron and folic acid, monthly household supply of iodised salt, and micronutrient-fortified balanced energy protein supplement for undernourished women), an enhanced infection management package (genitourinary tract infection screening and treatment, and enhanced deworming), or both packages. In the present Longitudinal Infant Development and Growth study, a subset of 480 children of mothers from ENAT will be recruited equally from each of the four study arms and visited at 12, 18, and 24 months of postnatal age. We will evaluate a range of domains and deploy multiple measures to assess child neurodevelopment, including resting electroencephalography and visual evoked potentials, Hammersmith Infant Neurological Examination, eye-tracking, Bayley Scales of Infant and Toddler Development (Bayley-III), and Magnetic Resonance Imaging (MRI). DISCUSSION/CONCLUSIONS:This study will advance understanding of the impact of nutrition and inflammation in pregnancy on long-term offspring neurodevelopment. This study aims to fill a critical knowledge gap on the benefits of prenatal interventions to promote the health of mothers and their offspring. ETHICS AND DISSEMINATION/BACKGROUND:This study was approved by the Institutional Review Boards of Addis Continental Institute of Public Health (ACIPH/IRB/002/2022) and Mass General Brigham (2023P000461). Results will be disseminated to local and international stakeholders. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT06296238.