IU Indianapolis ScholarWorks :: Browsing by Author "Stewart, Jesse"

Browsing by Author "Stewart, Jesse"

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Addressing Formal Thought Disorder in Psychosis through Novel Assessment and Targeted Intervention
(2020-08) Marggraf, Matthew P.; Minor, Kyle; Salyers, Michelle; Lysaker, Paul; Stewart, Jesse
Formal thought disorder (FTD) is a debilitating symptom of psychosis. It is linked to functional deficits and generally demonstrates poor response to interventions. Metacognition has emerged as a potential therapeutic target that may be effective in reducing FTD, as metacognitive deficits and FTD both arise from disruptions in associative thought processes. This study’s primary aim was to determine whether FTD could be reduced with metacognitive therapy. Pre-post changes in FTD severity were assessed using clinician-rated and automated measures in 20 individuals with psychotic disorders who received 12 sessions of evidence-based metacognitive therapy. We also examined whether reductions in FTD were larger when assessed with automated instruments versus clinician-rated measures. Aim two compared associations between FTD and three outcome variables (social functioning, role functioning, metacognition) across FTD-measurement approach. Results indicated that automated FTD, but not clinician-rated FTD, was significantly reduced post-intervention. This effect was more robust within a subsample exhibiting greater levels of FTD. Strength of associations between FTD and outcome variables did not differ across FTD measurement approach. These findings provide initial evidence that a targeted metacognitive intervention can reduce FTD. Effects were strongest for automated instruments, which may be more sensitive to detecting change; however, differences in measurement type did not extend to associations with selected outcome variables. This study provides preliminary support for future efforts to reduce FTD. Large-scale studies with longer intervention periods may further our understanding of the effectiveness of metacognitive intervention on FTD.
Bias in pain care: What patient variables do providers report as influencing their treatment decisions?
(2024-10) Rose-McCandlish, Margaret; Hirsh, Adam; Mosher, Catherine; Stewart, Jesse
Racialized and low socioeconomic status (SES) patients are often under-treated for chronic pain, despite reporting more pain on average. This disparity is likely due to multiple systemic factors, including healthcare provider bias. Providers often treat patients differently for chronic pain depending on the patient’s race and SES, but little is known about providers’ awareness of the extent to which patient demographic variables influence their pain treatment decisions. The present study examined the variables that providers report as influencing their pain treatment decisions, whether these variables group together to form distinct factors, and whether providers who demonstrate racial or socioeconomic bias in their treatment decisions report different patient variables or factors as influencing their treatment decisions compared to providers who did not demonstrate biases. Four hundred thirty-two United States-based physician residents and fellows (“providers”) made treatment decisions for 12 computer-simulated patients with chronic pain who varied by race (Black/White) and SES (high/low). Providers then rated the level to which 15 different variables influenced their treatment decision-making. Robust repeated measures ANOVAs indicated that providers rated patient sex/gender, age, and race as the least influential variables in their pain treatment decisions for the simulated patients. For the factor analysis, I sequentially omitted variables to achieve proper model fit and reliability and arrived at a three-factor solution; I labelled these factors Demographic, Biomedical, and Psychosocial, according to the variables’ conceptual overlap. Robust repeated measures ANOVAs found that reported use of variables did not differ between the providers who demonstrated bias and those who did not demonstrate bias, nor did factor scores for the three factors. The present study suggests that providers have low awareness of the extent to which patient race and SES may influence their clinical decision-making in pain care. Results can help inform future research to improve interventions to reduce the impact of racial and socioeconomic bias on providers’ treatment decisions for patients with chronic pain.
Depressive Symptom Severity, Stressful Life Events, and Subclinical Atherosclerosis in African American Adults
(2015) Berntson, Jessica; Stewart, Jesse; Cyders, Melissa Anne; Rand, Kevin L.; Grahame, Nicholas J.
Prospective epidemiologic evidence indicates that both stressful life events (SLEs) and depression are associated with an increased risk of subclinical atherosclerosis and cardiovascular disease (CVD) events. Even though stressful life events (SLEs) and depression co-occur and may act together to influence cardiovascular disease (CVD) risk, these psychosocial factors have been mainly examined in isolation. For instance, depression may moderate the relationship between SLEs and CVD outcomes. I hypothesized that depressive symptoms would potentiate the deleterious effect of SLEs on subclinical atherosclerosis. This hypothesis is plausible, given that depressed adults exhibit exaggerated and prolonged sympathetic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and inflammatory responses to stress, which in turn could promote atherosclerosis. As compared to their nondepressed counterparts, depressed individuals may also be more likely to engage in maladaptive methods to cope with SLEs (e.g., increased tobacco use, alcohol use, and consumption of low-nutrient, energy dense foods), which could also promote atherosclerosis. I examined cross-sectional data from 274 to 279 (depending on the outcome measure) older, African American adults (mean age = 66 years, 67% female) with no evidence of clinical CVD or dementia who participated in the St. Louis African American Health-Heart study (2009–2011). Number of SLEs was assessed using the Life Events Calendar, a structured interview. From this interview, a continuous SLEs variable was computed (number of adult SLEs: 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11+). Severity of depression symptoms was measured using the 17-item Hamilton Rating Scale for Depression (HAM-D). Two measures of subclinical atherosclerosis were obtained: carotid intima-media thickness (CIMT; assessed by ultrasonography) and coronary artery calcification (CAC; assessed by multi-detector computerized tomography). I conducted linear (CIMT) and logistic (CAC) regression models, first adjusted for demographics (age, sex, education) and then fully-adjusted (demographics; mean arterial pressure; low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C); hemoglobin A1c; BMI; tobacco use; diabetes diagnosis; and use of antihypertensitve, lipid lowering, antidiabetic, and antidepressant medications). No main effects of SLEs or HAM-D were found for CIMT or CAC. There were also no SLEs by HAM-D interactions for CIMT or CAC. Because the current results are largely inconsistent with prior literature and there is a paucity of studies utilizing African American samples, future research is needed to examine the independent and interactive associations of SLEs and depressive symptoms with measures of subclinical atherosclerosis. If the present results are replicated, it may suggest that SLEs, depressive symptoms, and their interactive effect are not cardiotoxic among African American adults.
Effect of Depression Treatment on Health Behaviors and Cardiovascular Risk Factors Among Primary Care Patients with Depression: Data from the eIMPACT Trial
(2023-12) Schuiling, Matthew D.; Stewart, Jesse; Hirsh, Adam; Wu, Wei
Background. Although depression is a risk factor for cardiovascular disease (CVD), few clinical trials in people without CVD have examined the effect of depression treatment on CVD-related outcomes. It’s unknown if successful depression treatment improves indicators of CVD risk, such as CVD-relevant health behaviors, traditional CVD risk factors, and CVD events. Methods. We examined data from eIMPACT trial, a phase II randomized controlled trial conducted from 2015-2020. Depressive symptoms, CVD-relevant health behaviors (self-reported CVD prevention medication adherence, sedentary behavior, and sleep quality) and traditional CVD risk factors (blood pressure and lipid fractions) were assessed. Incident CVD events over four years were identified using a statewide health information exchange. Results. The intervention group exhibited greater improvement in depressive symptoms (p < 0.01) and sleep quality (p < 0.01) than the usual care group, but there was no intervention effect on systolic blood pressure (p = 0.36), low-density lipoprotein cholesterol (p = 0.38), high-density lipoprotein cholesterol (p = 0.79), triglycerides (p = 0.76), CVD prevention medication adherence (p = 0.64), or sedentary behavior (p = 0.57). There was an intervention effect on diastolic blood pressure that favored the usual care group (p = 0.02). CVD-relevant health behaviors did not mediate any intervention effects on traditional CVD risk factors. Twenty-two participants (10%) experienced an incident CVD event. The likelihood of an CVD event did not differ between the intervention group (12.1%) and the usual care group (8.3%; HR = 1.45, 95% CI: 0.62-3.40, p = 0.39). Conclusions. Successful depression treatment alone improves self-reported sleep quality but is not sufficient to lower CVD risk of people with depression. Alternative approaches may be needed reduce CVD risk in depression. Trial Registration: ClinicalTrials.gov Identifier: NCT02458690
Effect of Depression Treatment on Somatic Depressive Symptoms and Cardiometabolic Biomarkers among People without Diabetes
(2022-05) Shell, Aubrey Lynn; Stewart, Jesse; Hirsh, Adam; Cyders, Melissa; Considine, Robert
While depression is a risk factor for type 2 diabetes, little is known about the effect of depression treatment on diabetes risk markers. Using data from the recently completed eIMPACT trial (NCT02458690, supported by R01 HL122245), I examined if depression intervention improves diabetes risk markers and if improvements in somatic depressive symptoms mediate potential intervention effects. 216 participants (primary care patients ≥50 years with depression and elevated cardiovascular disease risk from a safety net healthcare system) were randomized to 12 months of the eIMPACT intervention (modernized collaborative care intervention involving internet cognitive-behavioral therapy [CBT], telephonic CBT, and/or select antidepressants; n=107) or usual primary care for depression (primary care providers supported by embedded behavioral health clinicians and affiliated psychiatrists; n = 109). Given my focus on diabetes risk, I excluded participants who did not attend the post-treatment visit (n = 17) or who had a diabetes history at pre-treatment (n = 73), leaving a final sample of 126 (n=66 intervention, n=60 usual care; Mage = 58 years, 79% women, 50% Black, 47% with income <$10k/year). I computed depressive symptom severity variables from the Hopkins Symptom Checklist-20 (SCL-20) items: hyperphagia (“overeating” item), poor appetite (“poor appetite”), hypersomnia (“sleeping too much”), disturbed sleep (“sleep that is restless or disturbed”) and SCL-15 (mean of items not pertaining to appetite or sleep). I calculated insulin resistance from fasting plasma glucose and insulin using the Homeostasis Model Assessment for Insulin Resistance (HOMA-IR)-2 calculator, body mass index (BMI) from measured height and weight, and plasma concentrations of high-sensitivity C-reactive protein (hsCRP), leptin, and ghrelin using ELISA kits. Parallel mediation analyses revealed that 12 months of modernized collaborative care for depression improved both directions of sleep symptoms but did not improve poor appetite or hyperphagia – the somatic symptom most consistently linked with increases in HOMA-IR, BMI, hsCRP, and leptin. Of the five cardiometabolic biomarkers examined, the eIMPACT intervention decreased only hsCRP and ghrelin. There were no intervention effects on HOMA-IR, BMI, or leptin. In addition, no somatic depressive symptoms mediated intervention effects on the cardiometabolic biomarkers, nor did race moderate any mediation effects. Further research is warranted to determine best practices for targeting hyperphagia and reducing cardiometabolic disease risk among people with depression.
The effects of alcohol odor cues on food and alcohol attentional bias, cravings, and consumption
(2015-07-08) Karyadi, Kenny; Cyders, Melissa A.; Stewart, Jesse; Mosher, Catherine Esther; Grahame, Nicholas J.
In order to elucidate the role of classical conditioning in food and alcohol co-consumption, the present study examined: (1) the effects of alcohol odor cues on alcohol and food cravings and attentional bias (bias in selective attention toward either food or alcohol pictures relative to neutral pictures); and (2) the role of alcohol odor cue elicited cravings and attentional biases on subsequent consumption. Participants (n = 77; mean age = 30.84, SD = 9.46; 51.9% female, 83.1% Caucasian) first completed the lab portion of the study. In this portion, they were exposed to alcohol and neutral odorants, after which their food and alcohol cravings and attentional bias were assessed. Participants then received an online survey the next day, on which they reported their level of food and alcohol consumption following the lab portion of the study. Using repeated measures analysis of covariance, alcohol odor cues were differentially effective in increasing food and alcohol attentional bias and cravings (Fs= 0.06 to 2.72, ps= 0.03 to 0.81). Using logistic and multiple regressions, alcohol odor cue elicited alcohol attentional bias, food attentional bias, and food cravings were associated with later alcohol consumption, but not with later food consumption or concurrent consumption (βs = -0.28 to 0.48, ps = 0.02 to 0.99; Exp(B)s = 0.95 to 1.83, ps = 0.33 to 0.91). Overall, alcohol odor cues can become conditioned stimuli that elicit conditioned food-related and alcohol-related responses, both of which persist long enough to motivate later alcohol consumption; however, these conditioned responses might not persist long enough to motivate later food or concurrent consumption. These findings serve as a first step in clarifying the role of classical conditioning in concurrent consumption. In particular, they suggest that additional empirical investigations are needed to: (1) clarify the classical conditioning mechanisms underlying concurrent consumption; and (2) examine whether interventions targeting classical conditioning mechanisms are effective for reducing alcohol use.
Examining Relationships Among Depression Treatment, Brain-Derived Neurotrophic Factor (BDNF), and Depressive Symptom Clusters in Primary Care Patients with Depression
(2023-05) Crawford, Christopher A.; Stewart, Jesse; Rand, Kevin; Wu, Wei
Depression is a heterogeneous mental health condition, varying in presentation across individuals. A candidate etiology that may help account for this heterogeneity is the neurotrophin hypothesis of depression, which proposes that stress downregulates brain-derived neurotrophic factor (BDNF) expression, leading to aberrant neurogenesis and depression. This etiology may manifest in a distinct symptom profile that may be reflected in depressive symptoms or symptom clusters. The effect of psychological interventions on BDNF is not known. Additionally, it is not known if BDNF levels mediate intervention effects on depressive symptom clusters. Using data from the eIMPACT trial (NCT02458690, supported by R01 HL122245), I examined baseline associations of BDNF with depressive symptoms and depressive symptom clusters. Also, I examined if the modernized collaborative care intervention for depression (internet CBT, telephonic CBT, and select antidepressant medications) affected BDNF and if changes in BDNF mediated intervention effects on cognitive/affective and somatic depressive symptom clusters. 216 participants (primary care patients with depression and elevated cardiovascular disease risk ≥50 years from a safety net healthcare system) were randomized to 12 months of the eIMPACT intervention (n=107) or usual primary care for depression (primary care providers supported by embedded behavioral health clinicians and affiliated psychiatrists; n=109). Plasma BDNF was measured with commercial ELISA kits. Depressive symptoms were assessed by the PHQ-9 (M=15.1, SD=5.0) from which cognitive/affective and somatic subscale scores were computed. No significant baseline associations were observed between BDNF and individual depressive symptoms or depressive symptom clusters. The intervention did not improve BDNF over 12 months. Similarly, 12-month changes in BDNF were not associated with 12-month changes in PHQ-9 cognitive/affective or somatic subscale scores. However, the intervention significantly improved PHQ-9 cognitive/affective and somatic subscale scores over 12 months. 12-month changes in BDNF did not mediate the effect of the intervention on 12-month changes in the PHQ-9 subscale scores. These findings suggest that modernized collaborative care for depression does not improve BDNF. Modernized collaborative care does yield improvements in both cognitive/affective and somatic depressive symptom clusters, albeit not via changes in BDNF.
Examining the Effects of Contextually-Imposed Cognitive Load on Providers' Chronic Pain Treatment Decisions for Racially and Socioeconomically Diverse Patients
(2022-08) Anastas, Tracy; Hirsh, Adam; Salyers, Michelle; Stewart, Jesse; Kroenke, Kurt
Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.
Examining the influence of Hispanic ethnicity and ethnic bias on medical students’ pain decisions
(2016-05-09) Hollingshead, Nicole A.; Hirsh, Adam Todd; Ashburn-Nardo, Leslie; Stewart, Jesse; Maupomé, Gerardo; Grahame, Nicholas J.
Hispanic patients receive disparate pain care compared to non-Hispanic White (NHW) patients. Healthcare providers’ ethnic bias may be one reason for pain disparities. This investigation sought to determine the influence of Hispanic ethnicity and ethnic bias on chronic pain management decisions. During an online experiment, 97 medical students made pain assessment and opioid treatment decisions for Hispanic and NHW virtual human patients with chronic pain. They also completed explicit and implicit measures of ethnic bias. Individual-level analyses found that 31% and 36% of participants demonstrated large effect sizes (dz>.50), indicating that patient ethnicity strongly influenced their pain assessment and opioid treatment decisions, respectively. At the group level of analysis, participants’ decisions did not differ significantly between NHW and Hispanic patients (all p values >.05). Participants did not report significant explicit ethnic bias (t[96]=1.88, p=.06; dz=.19; Hispanic mean rating=77.6[SD=18.7]; NHW mean rating=75.2[SD=19.4]) but demonstrated a small-to-moderate implicit preference for NHWs relative to Hispanics (Mean=.31[SD=.41]). Patient ethnicity and implicit ethnic bias had an interactive effect on opioid treatment decisions (F[1, 95]=5.15, p<.05, generalized eta squared =.02); however, the direction of the effect was not as hypothesized. Participants with higher implicit ethnic bias gave significantly higher opioid ratings to Hispanics relative to NHWs (p=.05), whereas participants with lower bias gave marginally higher opioid ratings to NHWs relative to Hispanics (p=.20). Participants with higher vs. lower implicit ethnic bias differed only in their treatment ratings for NHW patients, such that participants with lower bias gave significantly higher opioid ratings to NHW patients than did participants with higher bias (p<.05). This investigation found that approximately one-third of participants made significantly different chronic pain management decisions for Hispanic vs. NHW patients. Participants’ implicit ethnic bias interacted with their opioid treatment decisions but not as expected. Future investigations should measure healthcare providers’ stereotypes about Hispanic patients with pain as this may better predict their pain decisions.
HiTOP-based Optimal Personalized Assignment to Abstinence from Alcohol: A Precision Medicine Approach
(2024-08) Argyriou, Evangelia; Cyders, Melissa; Wu, Wei; Stewart, Jesse; Plawecki, Martin
Abstinence from drinking has traditionally been the primary goal of alcohol use disorder (AUD) treatment; however, there is evidence that individuals respond differently when trying to be abstinent from alcohol. The main goal of my study was to use a novel precision medicine approach to optimize assignment to short-term abstinence from alcohol based on a variety of individual characteristics. The sample consisted of 97 moderate-to-heavy drinkers aged 21-35. A within-subjects design was employed where each participant completed two counter-balanced intravenous alcohol sessions (one following abstinence and one during usual drinking). For the primary aim of this study (N = 47), crossover generalized outcome weighted learning was used to estimate an optimal individualized assignment rule to short-term abstinence based on prescriptive factors, including HiTOP-relevant dimensions and other characteristics. For a secondary aim (N = 50), logistic regression was used to test whether the subgroups estimated by the optimal rule were associated with a set of genetic and behavioral factors related to AUD, and subjective perceptions to alcohol intoxication. Findings showed that an estimated rule with higher granularity – higher-specificity traits and demographics – led to lower alcohol consumption overall compared with one-size-fits-all rules (i.e., assigning everyone to abstinence or assigning no one to abstinence). The effect sizes of the difference were small-to-medium and fell short of statistical significance. Family history of AUD had a positive trend association with benefit from abstinence, with one standard deviation increase in family history of AUD being associated with twice as high odds of being assigned to abstinence. Due to the limited sample size, the results should be interpreted with caution. Study results provided preliminary evidence that an individualized assignment rule based on relatively simple and easily accessible individual characteristics can lead to lower alcohol consumption than that observed if everyone or no one was assigned to abstinence (i.e., one-size-fits-all approach). Genetic predispositions reflected in family history of AUD may be a potential mechanism linking the assessed prescriptive factors with abstinence response, which is worth further exploration.

Browsing by Author "Stewart, Jesse"

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