Archives for January 2022

Kasane V. Tonegawa

It is estimated that around 300 million people worldwide have been diagnosed with depression (World Health Organization, 2018). Depression is a mental illness that involves feelings of worthlessness, a lack of interest in previously enjoyable activities, thoughts of guilt, and changes in sleeping and eating patterns (National Alliance on Mental Illness, 2017). Depression can sometimes result in suicidal ideations (i.e., thoughts or plans to kill oneself; NAMI, 2017), which often act as a precursor to suicide, a leading cause of death in the United States (Murphy, Xu, Kochanek, Curtin, & Arias, 2017). Around one-third of those with depression have treatment-resistant depression (TRD); in other words, there is no reduction in depressive symptoms or the symptoms relapse, despite the use of common forms of treatment, such as antidepressant medication or psychotherapy (Rajkumar, Fam, Yeo, & Dawe, 2015; Warden, Rush, Trivedi, Fava, & Wisniewski, 2006). It is imperative that alternative forms of treatment are explored for the 100 million individuals around the world with TRD (WHO, 2018). Recently, commonly used recreational hallucinogens, such as Lysergic acid diethylamide (LSD) and psilocybin mushrooms, have been examined for their benefits for depression, obsessivecompulsive disorder, and post-traumatic stress disorder (Roseman, Nutt & Carhart-Harris, 2018). In 2019, the Food and Drug Administration approved of ketamine, an anesthetic typically used for pain relief and sedation, as a possible form of treatment for TRD (Berman et al., 2000; Niciu et al., 2018; Price, Nock, Charney, & Mathews, 2009). As such, this review aims to describe current and alternative treatment options for TRD, including a promising new avenue of research involving the use of low doses of ketamine.

Prevalent Treatment Options for TRD

Depression is typically treated with pharmacological drugs, psychotherapy, or a combination of the two (McConnell, Carter, & Patterson, 2019). Most antidepressant drugs increase the levels of neurotransmitters negatively correlated with depression, such as serotonin, dopamine, and norepinephrine (Epstein, Szpindel, & Katzman, 2014). The symptoms typically improve after two weeks of treatment, with a reduction in almost all symptoms in two months (McConnell et al., 2019). However, the symptoms might return or might not be alleviated at all, warranting a need for different treatment approaches that involve an increase in dosage, change of the drug type, or a combination of drugs (Epstein et al., 2014; McConnell et al., 2019; Shelton, Osuntokun, Heinloth, & Corya, 2010). Furthermore, physical side effects, such as weight gain or fatigue, and cognitive side effects, such as apathy and anhedonia, are also possible with pharmacological antidepressant treatments (Epstein et al., 2014; McConnell et al., 2019).

In order to increase the likelihood of efficacy, pharmacological treatment for depression is typically combined with a form of psychotherapy, in which the individual collaborates with a therapist to achieve relief of symptoms (Shelton et al., 2010). The most common form of psychotherapy used to treat depression is cognitive-behavioral therapy (CBT). CBT is an approach that is based on the assumption that the negative thought patterns and beliefs are what contribute to depressive symptoms (Dorasamy, 2019). In this form of treatment, a therapist and the client practice role playing and restructure thought patterns to stop or change habitual negative beliefs (Dorasamy, 2019). Although the combined treatment of CBT and antidepressants is typically more effective, relapses or failure to alleviate symptoms might occur (Dorsamy, 2019). When changes in dosage, drug types, and combinations of psychotherapy do not work, alternative forms of treatment— either pharmacological or non-pharmacological—can be used to treat TRD (Shelton et al., 2010).

Common non-pharmacological treatments include electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS; Kayser et al., 2011; Shelton et al., 2010). These forms of therapy are reserved as a last-resort or for urgent cases, such as risk of suicidality due to the negative cognitive side effects, including memory loss and confusion (Kayser et al., 2011; Kellner et al., 2012). ECT consists of inducing a brief seizure in the brain to increase levels of neurotransmitters dopamine and norepinephrine (Shelton et al., 2010). While ECT works faster and has a higher response rate than pharmacological treatments, it has a high rate of relapses, meaning the depressive symptoms may return (Kayser et al., 2011; Shelton et al., 2010). Alternatively, TMS works by regulating the neural activity in brain regions associated with depression (O’Reardon et al., 2007). Although TMS has fewer side effects compared to ECT, results from TMS typically appear only after two weeks and might even require several weeks for significant alleviation of symptoms (O’Reardon et al., 2007; Shelton et al., 2010). Therefore, although ECT and TMS are both effective forms of treatment, there are still cognitive side effects, high relapse rates, and long periods of time until alleviation is seen, thus meriting the need to examine unorthodox forms of treatment that are faster and more effective.

Alternative Treatments for TRD

Hallucinogens, or drugs that cause hallucinations when consumed, have recently become considered as a possible form 16 | Literature Reviews of treatment for TRD (Roseman et al., 2018). Some forms of therapy involving naturally-occurring hallucinogen—such as psilocybin mushrooms—are known as psychedelic therapy, in which small dosages of the drugs are administered in the presence and under the guidance of a therapist (Roseman et al., 2018). As with other forms of depression treatments, the exact mechanisms underlying the efficacy of the treatment are unclear. However, improvement in symptoms is related to the conscious “mystical” experience of the drug’s effects, rather than the targeting of specific neurotransmitters (Cahart-Harris et al., 2012; Roseman et al., 2018). In other words, the effects of the drugs are related to reported feelings of unity and awe that are experienced while on the drug (Cahart-Harris et al., 2012). This type of therapy is being examined for its unique approach to treating depression, as well as the quick alleviation of symptoms, which can be experienced in as little as an hour with two dosing sessions (Cahart-Harris et al., 2012). While the mechanisms underlying the efficacy of most antidepressant drugs occur on a neurochemical basis, the benefits of psychedelic therapy derive from the philosophical experiences that are induced by the hallucinogenic properties of the drugs (Cahart-Harris et al., 2012).

Another hallucinogenic drug is ketamine, an anesthetic that has historically been used to treat agitation and pain via sedation and numbing from low doses (Nichols & Paciullo, 2019). At a dissociative or high dose, the drug is known to have psychedelic effects, such as experiences of hallucinations and dissociation (Wolfson, 2014). Ketamine has the distinct benefit of alleviating suicidality in those with TRD and is, therefore, being examined more rigorously as a treatment option (Price et al., 2009, 2014). Nevertheless, because the mechanisms underlying the benefits are still unclear when treating TRD, ketamine and other hallucinogens are reserved as a last resort and require further research in order to better understand its effects (Ionescu & Papakostas, 2016).

How Ketamine Functions as an Antidepressant

Typical antidepressant drugs target neurotransmitters serotonin and norepinephrine, but this mechanism does not always permanently alleviate depressive symptoms in individuals with TRD (Rajkumar et al., 2015). As a result, alternative treatments, such as ketamine, might be a solution given that it targets a different neurotransmitter called glutamate (Gould, Zarate, & Thompson, 2019; Trullas & Skolnick, 1990). Glutamate is a neurotransmitter that has been linked to depression and suicidality when at abnormally low levels (Deutschenbauer et al., 2016) The receptors that glutamate latches onto are so active in those with depression that it decreases the amount of glutamate in the synapses, or the gaps between neurons (Deutschenbaur et al., 2016; Krystal, Sanacora, & Duman, 2013; Reinstatler & Youssef, 2015). Ketamine is an N-Methyl-D-Aspartate (NMDA) receptor antagonist, meaning it inhibits the activity of the glutamate receptors, which results in higher levels of glutamate between neurons (Deutschenbaur et al., 2016; Luckenbaugh et al., 2014). Because ketamine works to increase glutamate levels, it is hypothesized that its inhibitory effects on the receptors is one of the key factors in the drug’s antidepressant effects since it increases the neurotransmitter associated with elevated mood (Gould et al., 2019). Because ketamine targets a different neurotransmitter than typical antidepressant drugs, it is being explored as a promising alternative treatment to TRD.

Ketamine’s potential use as a treatment option is especially unique given its rapid-acting effects that specifically reduce suicidal ideations (Ballard et al., 2014; DiazGranados et al., 2010; Price et al., 2009, 2014; Murrough et al., 2015). In fact, a reduction in suicidal ideations was observed in as little as 40 minutes, suggesting that ketamine might be especially suited for immediate reductions in depressive symptoms, possibly due to the drug’s hallucinogenic and dissociative properties (Ballard et al., 2014; DiazGranados et al., 2010; Price et al., 2009, 2014). However, the reduction of suicidal ideations via ketamine treatment has not been fully examined, because research on the drug’s antidepressant use is still in its beginning stages (Rajkumar et al., 2015). Even so, there might be a relation between reduction in brain regions affected by ketamine’s dissociative properties and the drug’s role as an NMDA receptor antagonist, perhaps contributing to its antidepressant effects in individuals with TRD (Erhardt et al., 2013; Luckenbaugh et al., 2014; Sowa-Kucma et al., 2013).

Examining the brains of individuals who have attempted suicide has elucidated that the level of quinolonic acid (QUIN) is uniquely related to suicidal ideations (Erhardt et al., 2013; Rajkumar et al., 2015; Sowa-Kucma et al., 2013). QUIN is an NMDA receptor agonist that has opposite effects of ketamine, such that it activates, rather than inhibits, the glutamate receptors, resulting in lower levels of glutamate (Erhardt et al., 2013; Gould et al., 2019). Increased levels of QUIN, which decreases glutamate, was found in suicide attempters, indicating that glutamate is strongly related to suicidal ideations (Erhardt et al., 2013; Sowa-Kucma et al., 2013). Accordingly, if reduced levels of glutamate resulting from QUIN are connected to suicidal ideations, then the consequential increased levels of glutamate resulting from ketamine might be key to its antidepressant effects.

While ketamine is not the only NMDA receptor antagonist, other NMDA-antagonist drugs, such as phencyclidine and methadone, have not had the same rapid-acting reductions in suicidal ideations that ketamine has (Niciu et al., 2018). In particular, unlike other NMDA receptor antagonists that do not result in such a robust decrease in suicidal ideations, ketamine can lead to dissociation, or a sense of a detachment from oneself and one’s surroundings (Luckenbaugh et al., 2014; Niciu et al., 2018; Sos et al., 2013). In fact, the dissociative side effects have been positively correlated with the antidepressant response and elevated mood (Niciu et al., 2018; Sos et al., 2013). Additionally, brain regions related to depression and suicidal ideations—the hippocampus and prefrontal cortex—are particularly affected by the occurrence of dissociation induced by ketamine (Erhardt Literature Reviews | 17 Alternative Treatments for TRD et al., 2013; Rajkumar et al., 2015; Sowa-Kucma et al., 2013). In particular, the brains of suicide attempters have reduced hippocampal volume and show signs of dysfunction in the prefrontal cortex (Erhardt et al., 2013; Sowa-Kucma et al., 2013). The regions of the brain where abnormalities are related to suicidality are also related to dissociation, which is prompted by ketamine’s increase in glutamate levels. It is possible, then, that the drug’s effects on suicidality are linked, at least in part, to its dissociative effects in these brain areas (Rajkumar et al., 2015). Given that it is rapid, effective, and specifically targets suicidality, ketamine may be a promising treatment for those with TRD.

Conclusion

For the one-third of individuals with TRD, alternative treatments that provide faster alleviation and higher efficacy are being explored. These treatments include ECT, TMS, and psychedelic therapy. While ECT and TMS are faster than pharmacological treatment, there are still cognitive side effects to consider (Kayser et al., 2011; Shelton et al., 2010). With psychedelic therapies, such as psilocybin mushrooms, the unique experience-based characteristic may be key in its efficacy for TRD treatment (Cahart-Harris et al., 2012). One of f the most promising psychedelic treatments is ketamine, which works to reduce suicidality in TRD by specifically targeting the NMDA glutamate receptors in the hippocampus and prefrontal cortex to increase levels of glutamate, the neurotransmitter responsible for suicidal ideations (Erhardt et al., 2013; Luckenbaugh et al., 2014; Rajkumar et al., 2015). Much of the research on ketamine’s effects on TRD began with a focus on its general antidepressant use, but the drug may have unique benefits in terms of reducing suicidality given its dissociative properties (Rajkumar et al., 2015). Given the relatively recent discovery of ketamine’s possible medical use along with other psychedelic therapies, many studies have not yet been placebo-controlled, randomized, double-blinded, or used a large sample, thus making conclusion of causality difficult (Ballard et al., 2015; DiazGranados et al., 2010; Murrough et al., 2015, Rajkumar et al., 2015). The current literature review was explored from a theoretical perspective given the dearth of clinical trials with the drugs. Therefore, it is necessary to not only conduct studies with larger samples but to also measure suicidality with scales specifically targeting changes in suicidal ideation over short periods of time. Another consideration for future studies is examining the long-term effects of repeated administration of ketamine and other psychedelic drugs, such as potential dependency and tolerance. However, given the urgency required in treating suicidal TRD patients, it is likely that the potential benefits are greater than the costs (Rajkumar et al., 2015).

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Sarah Khullar

Although rates of mental illness are the same around the world, the number of people treated for mental health conditions differ greatly across countries (Kayrouz et al., 2018). In the Middle East, specifically, treatment rates of severe mental health disorders, such as non-affective psychosis, bipolar disorder, and depression, are significantly lower than the global prevalence of treatment for the same disorders (Kayrouz et al., 2018; WHO, 2017). Furthermore, stigma towards individuals with mental illness is more common in the Middle East in comparison to other regions, which might impact individuals’ choice of treatment (Sewilam et al., 2015). Of particular relevance are the beliefs and attitudes about mental illness that shape the perception of mental health services. Given the integral role of religion in everyday life, some individuals in the Middle East seek alternative options to cope with their mental health (Al-Krenawi, Graham, Dean, & Eltaiba, 2004; Ciftci, Jones, & Corrigan, 2013; Connors & Halligan, 2015; Corrigan & Penn, 1999; Zolezzi et al., 2018). Broader contextual factors, such as cultural values related to the family unit, also heavily impact one’s decision to seek out professional mental health services, especially considering the value placed on strong family units (Al-Krenawi et al., 2004; Gearing et al., 2012, 2015; Savaya, 1998). Thus, this review explores the following research question: how do the religious and familial values of Muslims in the Middle Eastern influence beliefs about mental illness and openness towards seeking mental health services?

Beliefs and Attitudes about Mental Illness from an Islamic Perspective

Islamic teachings on health stem from the Quran, the Holy Book, consisiting of revelations from God to the Prophet Muhammad, Hadiths (sayings of Prophet Muhammad), and Sira (Prophet Muhammad’s recorded actions and behaviors which are meant to serve as a guide for Muslims in certain situations; Bagasra & Mackinem, 2014; Haque, 2004). Those who adhere to the Islamic faith believe that God is all-knowing, and ascribe to the Quran’s assertion that faith provides security when faced with challenging life circumstances, as only God knows what is best for an individual (Haque, 2004). Muslims, thus, are taught to cope with mental health issues by seeking help from the Quran, asking God for help, praying, patience, faith, and hope (Haque, 2004).

Moreover, faith in Islam is seen as fostering positive mental health; having a strong relationship with God leads to a sense of empowerment. This premise leads some Muslims to believe that mental illness is a result of lack of faith (Mehraki & Gholami, 2017 Haque, 2014). In fact, Muslims in the Middle East often attribute spiritual reasons to causes of mental illness, believing that it is a punishment from God, or that one has been possessed by jinn, or evil spirits (Al-Krenawi et al., 2004; Ciftci et al., 2013; Sewilam et al., 2015). Others, however, attribute environmental and biological factors, such as chemical imbalances, stress, or genetics, as causes of mental illness (Al-Krenawi et al., 2009; Bagasra & Mackinem, 2014; Savaya, 1998).

Yet, many with this viewpoint also believe that the risk factors themselves serve as a test from God, or that they result from not following religious teachings on how to prevent mental illness through positive qualities (i.e., faith, patience and repentance; Bagasra & Mackinem, 2014; Mehraki & Gholami, 2017; Haque, 2004). When one breaks God’s rules, it can lead to feelings of psychological turmoil, or a sense of guilt (Haque, 2004). To alleviate these feelings, the Quran advises that Muslims engage in repentance as God loves to forgive, so long as one does not repeat the sin that they have asked forgiveness for (Haque, 2004). Consequently, some believe that strengthening one’s faith and repenting for one’s sins is a sufficient solution for problems that may arise in regards to mental health. Because patience is described in the Quran as a positive quality, which can cure all sorts of illness, there is a belief that one must be patient to see the results from these practices (Haque, 2004). Thus, some might avoid or delay professional help-seeking, given the importance that Islam stresses on patience and the promise of greater rewards as a result of suffering (Merhej, 2019). Overall, then, as a result of their religious values and beliefs, many Muslims will approach an Imam or a religious figure as one of the first steps in treating mental illness perhaps making individuals to be less open to seeking psychological or psychiatric treatment (Dardas & Simmons, 2015; Merhej, 2019; Savaya, 1998; Zolezzi et al., 2018).

Cultural Values and the Family Unit

Overall, Islam stresses the importance of taking care of one’s health by seeking professional treatment when needed, approaching illness with patience and prayer, and rejecting the stigmatization of others (Byrne et al., 2017; Haque, 2004). Thus, beliefs about mental illness stem largely from cultural values— and not from religious teachings (Dardas & Simmons, 2015; Kayrouz et al., 2018; Sewilam et al., 2015; Youssef & Deane, 2006; Zolezzi et al., 2018). Turning to religious leaders can often help mild symptoms of poor mental health through providing Sira and offering advice rooted in religion and religious values (Dardas & Simmons, 2015). However, turning to the family unit to alleviate mental health symptoms often precedes turning to religious leaders due to the important role that family plays in 12 | Literature Reviews Muslim communities (Ahsan & Ahsan, 2004; Savaya, 1998). Family and marriage provide emotional security and a stable environment to raise children, allowing parents to pass on Islamic teachings and the right morals and values to the next generation (Ahsan & Ahsan, 2004). From a cultural standpoint, an individual’s actions reflect upon the entire family unit; thus, the maintenance of family reputation and privacy heavily influences one’s behaviors (Abdel-Salam et al., 2019). Some may avoid seeking professional mental health services and might instead prefer to consult with those within the family and community religious leaders, often making individuals less open to seeking professional mental health treatment (AlDarmaki, 2003; Al-Krenawi et al., 2009; Gearing et al., 2012, 2015; Hassouneh & Kulwicki, 2009; Savaya, 1998).

Marriage also has cultural importance among Muslim families in the Middle Eastern region, often informing the social roles associated with women (Al-Krenawi et al., 2009; Ciftci et al., 2013; Gearing et al., 2015; Gearing et al., 2012). Culturally speaking, a man typically chooses a woman to marry (although women have every right to refuse or reject the offer); as a result, more focus might be placed on women’s reputations in an effort to avoid presenting as undesirable to prospective husbands (Dwairy, 2006). Additionally, due to the strong spiritual beliefs about the predictors of mental illness (e.g, being possessed by evil spirits called jinn), some people might believe the presence of a mental health disorder can prevent women from fulfilling their roles in the family unit, such as serving as the “child carer” of the family (Ahsan & Ahsan, 2004; Al-Krenawi et al., 2009; Ciftci et al., 2013; Gearing et al., 2012, 2015; Scull et al., 2014). In fact, those with mental health disorders can be seen as less intelligent, unable to look after themselves, and unable to handle responsibilities, all of which potentially limit marital prospects, as men might view these as negative qualities in a partner (Al-Krenawi et al., 2004; Bener & Ghuloum, 2010; Zolezzi et al., 2018). The potential negative impact on marriage prospects might consequently contribute to one’s willingness to seek professional mental health services, especially given that maintaining the family unit is a strong cultural value among Muslims living in the Middle East (Abdel-Salam et al., 2019; AlKrenawi et al., 2009, 2004; Kayrouz et al., 2018).

The shame associated with a severe psychiatric diagnosis or a family member’s behavior might also bring shame to the entire family, resulting in “associative stigma” (El-Islam 1994; Zolezzi et al., 2018). The Arabic word alwasm attributes shame by labelling individuals exhibiting socially and culturally unacceptable behaviors as unfit members of society (Dardas & Simmons, 2015). Furthermore, haram (religiously forbidden) is tied to religious doctrine and is used in circumstances when an individual acts in a manner alternative to religious requirements (Ajrouch, 2004). These terms label an individual’s behavior; however, they may also attribute blame to the family by implying that the individual’s family condoned or failed to teach an individual why that particular behavior is deemed haram or aib (Ahsan & Ahsan, 2004; Ajrouch, 2004). Beliefs that those Muslim communities (Ahsan & Ahsan, 2004; Savaya, 1998). with a mental illness should not get married, have children, and are unable to sustain friendships are often attributed to the shame and embarrassment others feel when associated with someone who has a mental illness (Zolezzi et al., 2018). Thus, an individual’s decision to seek treatment is often influenced by their attempt to avoid bringing associative stigma to their family, as family interests are often prioritized over individual interests (Abdel-Salam et al. 2019; Zolezzi et al., 2018).

Additionally, some women might experience even higher levels of shame due to a cultural belief that Muslim women represent a family’s sharaf, or honor (Abdel-Salam et al., 2019; Bener & Ghuloum, 2010). Consequently, some married women might be less likely to share mental health concerns with others or seek treatment, out of fear of harming their own reputation, as well as their family’s (Al-Krenawi et al., 2004). Given that many believe that the family unit serves as a source of emotional support and socialization, sharing personal issues outside the family might lead to negative attitudes towards the family (Ahsan & Ahsan, 2004). In fact, female Muslims express feeling hyper-aware of familial and societal expectations, particularly due to maintaining family honor and reputation – behaving in ways deemed socially appropriate – and acting in accordance with cultural gender roles (Abdel-Salam et al., 2019). Because maintaining family honor is an important cultural value in Muslim culture in the Middle East, the fear of shame can reduce a family member’s openness to seeking psychological or psychiatric care (Al-Krenawi et al., 2004). This, in turn, results in delaying seeking professional services until an individual displays severe symptoms, others have noticed the symptoms, or treatments through an Imam have been exhausted (Bener & Ghuloum; Dardas & Simmons, 2015).

Conclusion

Overall, Muslim religious and family cultural values influence the beliefs and attitudes associated with mental illness, informing how mental health is approached and addressed. In some communities, having a severe psychological disorder has implications for the family unit and marital prospects, perhaps reflecting a family’s inability to effectively teach Muslim religious and cultural values. Given the expectation of placing family interests before one’s own, individuals in the Middle East might not seek out professional mental health services. Yet existing literature rarely discusses the potential differences in openness to mental health services across generations, primarily due to the lack of research on specific age groups. Future studies might address this limitation, as there are generational differences in following Islamic values (Haque, 2004). Perceptions of mental illness also vary by level of education and exposure to Western or modern mental health services (Zolezzi et al., 2018). Culturally relevant models have crucial implications for the successful design and implementation of mental health interventions, as religion is a key contextual factor that influences the accessibility of treatment. Thus, psychological and psychiatric services Literature Reviews | 13 Openness Toward Mental Health Services should provide access to resources to increase knowledge on the causes, symptoms and treatment of mental illness, while also considering the potentially critical role of faith-based services in this population.

References

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Ahsan, N., & Ahsan, H. (2004). Foundation of a family: Importance, obstacles and possible solutions. Policy Perspectives, 1(1), 95-107.

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Al-Krenawi, A., Graham, J. R., Dean, Y. Z., & Eltaiba, N. (2004). Cross-national study of attitudes towards seeking professional help: Jordan, United Arab Emirates (UAE) and Arabs in Israel. International Journal of Social Psychiatry, 50(2), 102-114.

Bener, A., & Shuloum, S. (2010). Gender differences in the knowledge, attitude and practice towards mental health illness in a rapidly developing Arab society. International Journal of Social Psychiatry, 57(5), 480-486.

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Dardas, L. A., & Simmons, L. A. (2015). The stigma of mental illness in Arab families: A concept analysis. Journal of Psychiatric and Mental Health Nursing, 22(9), 668-679.

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Gearing, R. E., Schwalbe, C. S., MacKenzie, M. J., Brewer, K. B., Ibrahim, R.W., Olimat, H. S., … Al-Krenawi, A. (2012). Adaptation and translation of mental health interventions in Middle Eastern Arab countries: A systematic review of barriers to and strategies for effective treatment implementation. International Journal of Social Psychiatry, 59(7), 671-681.

Haque, A. (2004). Religion and mental health: The case of American Muslims. Journal of Religion and Health, 43(1), 45-58.

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Savaya, R. (1998). The under-use of psychological services by Israeli Arabs: An examination of the roles of negative attitudes and the use of alternative sources of help. International Social Work, 41(2), 195-209.

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Zolezzi, M., Alamri, M., Shaar, S., & Rainkie, D. (2018). Stigma associated with mental illness and its treatment in the Arab culture: A systematic review. International Journal of Social Psychiatry, 64(6), 597-609.

Maggie Zhang

Inhibitory control and emotional regulation have long term implications for academic achievement and social functioning starting in early childhood (Anzman-Frasca, Francis, & Birch, 2015; Blandon, Calkins, & Keane, 2010; Carlson & Wang, 2007; Fan, Liberman, Keysar, & Kinzler, 2015; King, Lengua, & Monahan, 2013; Oades-Sese et al., 2011; Rhoades, Greenberg, & Domitrovich, 2009). Both emotional regulation and inhibitory control have underpinnings in the prefrontal cortex of the brain, suggesting that there may be a link between these two processes (Blair, 2002; Martin & Ochsner, 2016; Ochsner & Gross, 2005). Inhibitory control is a cognitive skill that refers to the ability to control one’s thoughts and actions and facilitates children’s emotional regulation, which allows an individual to respond appropriately in social situations (Carlson & Wang, 2007; Hudson & Jacques, 2014; Šimleša, Cepanec, & Marta Ljubešić, 2017). Past research has highlighted the potential advantages of early exposure to or fluency in more than one language for inhibitory control, suggesting that early childhood bilinguals exhibit greater inhibitory control than monolinguals (Bialystok, 2017; Bialystok, Martin, & Viswanathan, 2005). Thus, it seems plausible that early childhood bilingualism might strengthen the relation between inhibitory control and emotional regulation. Therefore, the current review explores the following research question: Does inhibitory control enriched by early childhood bilingualism promote positive emotional regulation development? This paper focuses on research conducted with bilingual participants, in English and another language, who were exposed to both languages at home, at school, or with family members at least 10-25% of the time every day since birth (Byers-Heinlein & Lew-Williams, 2013). Emotional Regulation and Inhibitory Control

The development of inhibitory control and emotional regulation begins in early childhood (Anzman-Frasca et al., 2015; Carlson & Wang, 2007; Rhoades et al., 2009). Researchers exploring the relation between inhibitory control and emotional regulation typically create a scenario where the child receives a disappointing gift at the end of participating in a research study and have found that children who had higher levels of inhibitory control were significantly better at regulating their emotions and masking their disappointment by still reacting positively when receiving the gift (Carlson & Wang, 2007; Hudson & Jacques, 2014). By contrast, children with lower levels of inhibitory control had difficulty hiding their negative emotionality and looked or acted visibly upset over the gift (Carlson & Wang, 2007; Hudson & Jacques, 2014).

Emotional regulation is essential for child development and has implications for academic achievement and social functioning (Birch & Ladd, 1997; Eisenberg et al., 1995; English et al., 2012; Graziano, Reavis, Keane, & Calkins, 2007; Gumora & Arsenio, 2002; Rydell, Thorell, & Bohlin, 2007; Trentacosta & Shaw, 2009; Valiente et al., 2010). Beginning in early childhood, emotional regulation predicts preschoolers’ academic achievement; students who display more emotional regulation have stronger relationships with their teachers, which, in turn, contributes to higher rates of early academic success and productivity (Birch & Ladd, 1997; Graziano et al., 2007; Gumora & Arsenio, 2002; Valiente et al., 2010). Emotional regulation also impacts social behaviors starting in preschool, with teachers and peers viewing students who have a greater ability to self-regulate and positive social relationships, more favorably (Birch & Ladd, 1997; Blair, Denham et al., 2004; Eisenberg et al., 1996; Graziano et al., 2007; McDowell, Kim, O’Neil, & Parke, 2002). Thus, inquiry into the mechanisms that enrich the associations between inhibitory control and emotional regulation is of particular importance. Once such mechanism might be childhood bilingualism.

Early Childhood Bilingualism Enriches Inhibitory Control

The Bilingual Inhibitory Control Advantage (BICA) argument speculates that bilinguals perform better than monolinguals on tasks that require inhibitory control (Green, 1998). This argument is supported by research that has found that bilinguals demonstrate more instances of inhibitory control than monolinguals (Bialystok et al., 2005; Bialystok, 2017). One possible explanation for this advantage is that bilinguals simultaneously use one language while inhibiting interferences from the other language (Esposito, Baker-Ward, & Mueller, 2013; Hannaway, Opitz, & Sauseng, 2019). The active suppression of the second language, while using the intended one, demonstrates inhibitory control.

The most common method for measuring the relation between bilingualism and inhibitory control is through tasks such as the Stroop and Simon Tasks (see Figure 1 and Figure 2). Both tasks require participants to focus on one aspect of the task while ignoring irrelevant information, a core element of inhibitory control (Stevens & Bavelier, 2012). Supporting the BICA hypothesis, bilinguals were found to have higher instances of inhibitory control compared to monolinguals on both tasks, such that bilinguals were better able to suppress contradictory stimuli (e.g., the color of the word) and reacted faster than monolinguals (Bialystok et al., 2005; Bialystok, 2017; Blumenfeld & Marian, 2011; Esposito et al., 2013; Hartanto & Yang, 2019). Literature Reviews | 7 OPUS (2020) 11:1

Given that bilinguals outperform monolinguals on tasks such as the Simon and Stoop Tasks, it is important to explore how early childhood bilingualism could be a factor that enhances inhibitory control and emotional regulation in children raised in bilingual households (Fan et al., 2015; Oades-Sese et al., 2011). In fact, greater inhibitory control is associated with greater social skills and academic achievement in bilingual children, due to their ability to control or adjust their behaviors in response to challenging situations and thereby more easily self-regulate (Carlson & Wang, 2007; Hartanto & Yang, 2019; Hilchey & Klein, 2011; Liu et al., 2019; Lukasik et al., 2018; Rhoades et al., 2009). Since early childhood bilingualism enriches inhibitory control and inhibitory control is linked with emotional regulation, growing up in a bilingual household could promote emotional regulation and effective communication (Fan et al., 2015; Oades-Sese et al., 2011). In fact, bilingual children as young as four-years-old have a greater ability to inhibit negative emotions in social settings and show more flexibility when responding to social situations, such as reacting calmly and positively to a disagreement (Carlson & Wang, 2007; Denham et al., 2003; Fan et al., 2015; Oades-Sese et al., 2011). Both emotional regulation and inhibitory control are necessary for bilinguals to restrain their own thoughts and actions in frustrating moments, enabling them to appear more emotionally regulated and deemed as likeable by their peers (Fan et al., 2015). Early childhood bilingualism thus appears to serve as a moderator for the relation between inhibitory control and emotional regulation, although more research on this topic is needed.

Conclusion

Past findings support the BICA hypothesis, with bilinguals exhibiting greater inhibitory control and emotional regulation compared to monolinguals (Bialystok et al., 2005; Bialystok, 2017; Blumenfeld & Marian, 2011; Esposito et al., 2013; an et al., 2015; Hartanto & Yang, 2019; Oades-Sese et al., 2011). These advantages in inhibitory control and emotional regulation are noteworthy, because early childhood bilingualism could potentially offer an explanation for the greater academic achievement and social functioning in bilinguals compared to their monolingual peers (Fan et al., 2015; Oades-Sese et al., 2011).

Although a robust amount of literature has examined early childhood bilingualism, future research should examine how the development of inhibitory control differs for people bilingual in English and another written language, such as Spanish, compared to people bilingual in character based languages (e.g., Chinese). Additionally, to see the long term effects of early childhood bilinguals, more longitudinal studies should be conducted in order to see how early childhood bilingualism impacts the development of inhibitory control throughout their life, rather than conducting comparison studies for one age group at a time. These findings can have implications in practice and policy by emphasizing the importance of offering different language exposure in schools. Given the growing amount of bilingual children in the United States, research should support the importance of bilingual schooling, especially in communities with large immigrant populations.

References

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Bialystok, E. (2017). The bilingual adaptation: How minds accommodate experience. Psychological Bulletin, 143(3), 233-262.

Bialystok, E., Martin, M. M., & Viswanathan, M. (2005). Bilingualism across the lifespan: The rise and fall of inhibitory control. International Journal of Bilingualism, 9(1), 103–119.

Birch, S. H., & Ladd, G. W. (1997). The teacher-child relationship and children’s early school adjustment. Journal of School Psychology, 35(1), 61-79.

Blair, K. A., Denham, S. A., Kochanoff, A., & Whipple, B. (2004). Playing it cool: Temperament, emotion regulation, and social behavior in preschoolers. Journal of School Psychology, 42(6), 419-443.

Blair, C. (2002). School readiness. American Psychologist, 57(2), 111-127. Blandon, A. Y., Calkins, S. D., & Keane, S. P. (2010). Predicting emotional and social competence during early childhood from toddler risk and maternal behavior. Development and Psychopathology, 22(1), 119-132.

Blumenfeld, H. K., & Marian, V. (2011). Bilingualism influences inhibitory control in auditory comprehension. Cognition, 118(2), 245-257.

Byers-Heinlein, K., & Lew-Williams, C. (2013). Bilingualism in the early years: What the science says. LEARNing Landscapes, 7(1), 95-112. Carlson, S. M., & Wang, T. S. (2007). Inhibitory control and emotion regulation in preschool children. Cognitive Development, 22(4), 489-510.

Denham, S. A., Blair, K. A., DeMulder, E., Levitas, J., Sawyer, K., Auerbach-Major, S., & Queenan, P. (2003). Preschool emotional competence: Pathway to social competence? Child Development, 74(1), 238-256.

Eisenberg, N., Fabes, R. A., Murphy, B., Karbon, M., Smith, M., & Maszk, P. (1996). The relations of children’s dispositional empathy-related responding to their emotionality, regulation, and social functioning. Developmental Psychology, 32(2), 195-209.

Eisenberg, N., Fabes, R. A., Murphy, B., Maszk, P., Smith, M., & Karbon, M. (1995). The role of emotionality and regulation in children’s social functioning: A longitudinal study. Child Development, 66(5), 13-60.

English, T., John, O. P., Srivastava, S., & Gross, J. J. (2012). Emotion regulation and peer-rated social functioning: A four-year longitudinal study. Journal of Research in Personality, 46(6), 780-784.

Esposito, A. G., Baker-Ward, L., & Mueller, S. T. (2013). Interference suppression vs. response inhibition: An explanation for the absence of a bilingual advantage in preschoolers’ stroop task performance. Cognitive Development, 28(4), 354-363.

Fan, S. P., Liberman, Z., Keysar, B., & Kinzler, K. D. (2015). The exposure advantage. Psychological Science, 26(7), 1090-1097.

Graziano, P. A., Reavis, R. D., Keane, S. P., & Calkins, S. D. (2007). The role of emotion regulation in children’s early academic success. Journal of School Psychology, 45(1), 3-19.

Green, D. W. (1998). Mental control of the bilingual lexicosemantic system. Bilingualism: Language and Cognition, 1(2), 67-81.

Gumora, G., & Arsenio, W. F. (2002). Emotionality, emotion regulation, and school performance in middle school children. Journal of School Psychology, 40(5), 395-413.

Hannaway, N., Opitz, B., & Sauseng, P. (2019). Exploring the bilingual advantage: Manipulations of similarity and second language immersion in a stroop task. Cognitive Neuroscience, 10(1), 1-12.

Hartanto, A., & Yang, H. (2019). Does early active bilingualism enhance inhibitory control and monitoring? A propensitymatching analysis. Journal of Experimental Psychology. Learning, Memory, and Cognition, 45(2), 360-378.

Hilchey, M., & Klein, R. (2011). Are there bilingual advantages on nonlinguistic interference tasks? Implications for the plasticity of executive control processes. Psychonomic Bulletin & Review, 18(4), 625-658.

Hudson, A., & Jacques, S. (2014). Put on a happy face! Inhibitory control and socioemotional knowledge predict emotion regulation in 5- to 7-year-olds. Journal of Experimental Child Psychology, 123, 36-52. King, K.,

Lengua, L., & Monahan, K. (2013). Individual differences in the development of self-regulation during pre-adolescence: Connections to context and adjustment. Journal of Abnormal Child Psychology, 41(1), 57-69.

Liu, C., Yang, C., Jiao, L., Schwieter, J. W., Sun, X., & Wang, R. (2019). Training in language switching facilitates bilinguals’ monitoring and inhibitory control. Frontiers in Psychology, 10, 18-39.

Lukasik, K. M., Lehtonen, M., Soveri, A., Waris, O., Jylkkä, J., & Laine, M. (2018). Bilingualism and working memory performance: Evidence from a large-scale online study. PLoS One, 13(11), 1-16.

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Oades-Sese, G. V., Esquivel, G. B., Kaliski, P. K., & Maniatis, L. (2011). A longitudinal study of the social and academic competence of economically disadvantaged bilingual preschool children. Developmental Psychology, 47(3), 747- 764.

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Rhoades, B. L., Greenberg, M. T., & Domitrovich, C. E. (2009). The contribution of inhibitory control to preschoolers’ social–emotional competence. Journal of Applied Developmental Psychology, 30(3), 310-320.

Rydell, A., Thorell, L. B., & Bohlin, G. (2007). Emotion regulation in relation to social functioning: An investigation of child self-reports. European Journal of Developmental Psychology, 4(3), 293-313.

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Trentacosta, C. J., & Shaw, D. S. (2009). Emotional self-regulation peer rejection, and antisocial behavior: Developmental associations from early childhood to early adolescence. Journal of Applied Developmental Psychology, 30(3), 356- 365.

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Figure 1. The Stroop Task presents the word of the color associated with a different color. For example, the word presented is “red” but the color of the ink is in green. Participants are then asked to say the color of the ink instead of the word.

Figure 2. The Simon Task has participants press the left key if the blue circle appears and the right key if the red circle appears.

Letter from the Editors

Gender & Development

• The Impact of Stereotypes on Girls’ Career Choices – Katie Mundt
• The Effects of Social Media Networks on the Self-Esteem of Adolescent Girls – Ancelma Vasquez
• Body Dissatisfaction: Adolescent Girls and Disordered Eating Behaviors – Abby Rusnack

Gender, Sexuality, & Inequality

• Mental Health: Gender-Based Discrimination Experienced by TGNC Individuals – Olivia Russo
• Effects of Minority Stress on Lesbian, Bisexual, Transgender, and Queer People of Color – Julia Leschi 

Biographies

Maya Metser (she/her) | Editor-in-Chief | mm9188@nyu.edu

Maya is a senior in the Applied Psychology program. She is currently pursuing an Honors thesis under the mentorship of Dr. Natalie H. Brito at the ISLAND Lab, where she is exploring the effects of mother-infant heart rate synchrony on infant attention outcomes. In the past, she was an advocate for the ROSES research team and a research assistant at the SCAN Lab, a fetal neuroimaging lab. Moving forward, she hopes to bridge her passion for neuroscience, education, and juvenile justice reform to make early environments better support positive development. Lastly, Maya hosts a podcast called Psych Mic that explores the lives and career paths of industry leaders who use psychology to make an impact in the world. Psych Mic highlights psychology’s versatile applications and provides practical advice about opportunities in the field.

Katie Mundt (she/her) | Editor-in-Chief | kvm256@nyu.edu

Katie is a fall graduate of the Global Public Health/Applied Psychology program. She is interested in improving community health through a psychological lens, applying the skills and theories from psychology to health research and policy reform. She worked at NYU Langone on the Smoke-Free Housing Project, which evaluated the effectiveness of a smoke-free policy in NYC public housing developments. Currently, she works as a research assistant for the RISE lab and has helped develop a grant-awarded research proposal for the Social Perception Action & Motivation (SPAM) lab, which examined how the media’s portrayal of the COVID-19 pandemic impacts perception and subsequent behavior. After graduation, she hopes to continue working in public health and policy research, eventually seeking a Masters in Public Health.

Olivia Russo (she/her) | Editor-in-Chief | op496@nyu.edu

Olivia is a senior in the Applied Psychology program, double majoring in Gender & Sexuality Studies. She is passionate about bridging psychology and gender & sexuality, evident by her research interests and experience. She is currently a research assistant on Dr. Yoshikawa’s Gender and Sexuality Alliance Research Consortium (GSARC), where she is involved on two smaller projects as well, the Principal Interview Study, exploring school principals’ experiences with the LGBTQIA+ community, and the Dissemination Efforts team, creating resources for high-school GSAs based on previous GSARC research. Olivia plans to pursue a Master’s in Mental Health and Counseling, with a specialization in working with sexual and gender minority populations, upon graduation.

Julia Leschi (she/her) | Contributing Writer | jel623@nyu.edu

Julia is a senior in the Applied Psychology program with a minor in Public Health. She is interested in applying a psychological lens to public health and policy issues. In the past, she worked as a clinical assistant at a substance use clinic in Midtown Manhattan. She is currently working as the Assistant Director of Research at the Empower Lab where she studies sugar dating practices on college campuses, and the health needs of human trafficking survivors. In the future, she hopes to put her research skills in service of policy reform and community work before continuing her education.

Abby Rusnak (she/her) | Contributing Writer | alr606@nyu.edu

Abby Rusnak is a senior in the Applied Psychology program with a double minor in Child and Adolescent Mental Health Studies and Studio Art. She is interested in working with children and adolescents in clinical settings. In the past she has worked at several social skills summer camps for children with ADHD and other behavioral and disruptive disorders. She was also a research assistant at NYU’s lab for Strengthening the Architecture for High Quality Universal Pre-K, which partners with the NYC Department of Education to improve the quality of Pre-K across New York City. Currently, Abby is a Program Assistant at The Child Mind Institute where she works one-to-one with children who have selective mutism and ADHD disorders. Her work at The Child Mind Institute has encouraged her to seek a PsyD in clinical psychology in the future.

Ancelma Vazquez (she/her) | Contributing Writer | avm365@nyu.edu

Ancelma is a senior in the Applied Psychology program. Throughout her undergraduate career, Ancelma has been a data collector for ROSES at the RISE Lab at NYU, as well as, a research assistant at the BELLE Project at NYU Langone. Currently, she is a research assistant at SMART Beginnings, where she explores cross-linguistic variation among monolingual and bilingual children. In the future, she hopes to continue exploring the inequities facing low-income children and families in predominantly Latinx communities, before continuing her education in social policy and intervention.

Grace Park (she/her) | Layout and Design Director | hjp332@nyu.edu

Grace is a junior in Applied Psychology minoring in Nutrition and Dietetics. She is interested in raising awareness of mental health in minority communities and hopes to help such populations by providing culturally competent care. Grace will be working as a research assistant for The Listening Project which aims to train middle school students and their teachers in a semi-structured method of interviewing with the goal of enhancing listening skills, empathy, trust, academic engagement and achievement as well as disrupting stereotypes and building relationships across difference. Grace ultimately hopes to complete her masters at NYU for Counseling for Mental Health and Wellness

Sydney Liang (she/her) | Layout and Design Director | syl569@nyu.edu

Sydney is a junior in the Applied Psychology program with a minor in Media, Culture, and Communication. She is currently a research assistant at the Play and Language Lab, which examines how children interact with their environment as well as how social and cultural factors influence children’s development. Previously, she was a volunteer at L-FELD, where she provided assistance in an elementary school classroom. In addition to delving into her interest in developmental psychology, she is also involved in exploring opportunities pertaining to industrial-organizational psychology and the nonprofit sector. She plans on continuing to experience various paths which highlight the intersection between psychology and other fields before pursuing higher education.

Chloe Carlson (she/her) | Layout and Design Director | cec747@nyu.edu

Chloe is a sophomore in Applied Psychology with a strong interest in the effects of media on the mind. While pursuing a minor in Media, Culture, and Communication, she hopes to assist in the creation of more psychology related media in order to raise mental health awareness and educate others