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Haag C, So M, Vainre M, Kleim B, Dalgleish T, Hitchcock C. Positive autobiographical memories to counteract low mood in remitted depression: A longitudinal daily-life investigation. Emotion 2024; 24:1709-1720. [PMID: 38900552 DOI: 10.1037/emo0001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Positive autobiographical memories (AMs) have the potential to repair low mood, but previously depressed individuals have difficulty leveraging their positive AMs for emotion regulation purposes. We examined whether previously depressed individuals benefit from guided, deliberate recollection of preselected AMs to counteract low mood in daily life, utilizing individuals' smartphones to facilitate recollection. Sixty participants enrolled in 2020 were randomly allocated to retrieval of positive or everyday activity AMs and completed ecological momentary assessment of emotional experience for 3 weeks. Participants first created a pool of six memories for the digital AM diary. This was followed by a training week with two recollection tasks daily and a 2-week follow-up period where the diary could be used spontaneously. The positive condition experienced a greater increase in feelings of happiness and a greater decrease in feelings of sadness from pre- to post-AM recollection. While participants in the positive condition used the AM technique more frequently overall during the 2-week follow-up, the effect of condition was moderated by changes in feelings of sadness. The more participants experienced an emotional benefit during the training week, the more they used it spontaneously. Emotional vividness of untrained positive AMs at the 2-week follow-up differed depending on whether they were assessed before or after the first pandemic lockdown. Residual depressive symptoms decreased in both conditions over the study course, while mental well-being remained unchanged. Strengthening positive, self-affirming AMs in daily life may provide a tool to support regulation of transient low mood in those remitted from depression. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Mistica M, Haylock P, Michalewicz A, Raad S, Fitzgerald E, Hitchcock C. A natural language model to automate scoring of autobiographical memories. Behav Res Methods 2024; 56:6707-6720. [PMID: 38664340 PMCID: PMC11362422 DOI: 10.3758/s13428-024-02385-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 08/30/2024]
Abstract
Biases in the retrieval of personal, autobiographical memories are a core feature of multiple mental health disorders, and are associated with poor clinical prognosis. However, current assessments of memory bias are either reliant on human scoring, restricting their administration in clinical settings, or when computerized, are only able to identify one memory type. Here, we developed a natural language model able to classify text-based memories as one of five different autobiographical memory types (specific, categoric, extended, semantic associate, omission), allowing easy assessment of a wider range of memory biases, including reduced memory specificity and impaired memory flexibility. Our model was trained on 17,632 text-based, human-scored memories obtained from individuals with and without experience of memory bias and mental health challenges, which was then tested on a dataset of 5880 memories. We used 20-fold cross-validation setup, and the model was fine-tuned over BERT. Relative to benchmarking and an existing support vector model, our model achieved high accuracy (95.7%) and precision (91.0%). We provide an open-source version of the model which is able to be used without further coding, by those with no coding experience, to facilitate the assessment of autobiographical memory bias in clinical settings, and aid implementation of memory-based interventions within treatment services.
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Hitchcock C, Fitzpatrick S. Broadening accessibillity and scalability of interventions for trauma-related conditions. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2024. [PMID: 39295155 DOI: 10.1111/bjc.12500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 08/13/2024] [Indexed: 09/21/2024]
Abstract
OBJECTIVES Trauma-related conditions, such as post-traumatic stress disorder, are associated with high rates of impairment and distress. Evidence-based interventions for many trauma-related conditions exert robust effects on their primary outcomes. However, logistical, financial, geographic and stigma-related barriers to accessing these interventions exist. METHODS Innovations that overcome barriers to access and engagement and increase the scalability of interventions for trauma-related conditions are sorely needed. RESULTS AND CONCLUSIONS Here, we explore the following two potential avenues towards meeting this need: changes to the delivery model, including embedding interventions in settings which are already accessed by trauma-exposed individuals (e.g. schools, social care systems) and harnessing advancements in technology to provide truly accessible trauma-focussed interventions.
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Reed J, Meiser-Stedman R, Dalgleish T, Goodall B, Wright I, Boyle A, Burgess A, Murphy F, Hitchcock C, Schweizer S, Travers-Hill E, Dixon C, Mul CL, Smith P, Newby J, McKinnon A. Trauma Memory Characteristics and Neurocognitive Performance in Youth Exposed to Single-Event Trauma. Res Child Adolesc Psychopathol 2024; 52:997-1008. [PMID: 38329684 PMCID: PMC11108885 DOI: 10.1007/s10802-024-01171-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
Cognitive models of posttraumatic stress disorder (PTSD) highlight characteristics of trauma memories, such as disorganisation, as key mechanisms in the aetiology of the disorder. However, studies investigating trauma memory in youth have provided inconsistent findings. Research has highlighted that PTSD in youth may be accompanied by difficulties in neurocognitive functioning, potentially impacting ability to recall the trauma memory. The present study sought to investigate both trauma memory characteristics and neurocognitive functioning in youth aged 8-17 years. Youths exposed to single-event trauma, with (N = 29, Mage = 13.6, 21 female) and without (N = 40, Mage = 13.3, 21 female) a diagnosis of PTSD, completed self-report measures of trauma memory, a narrative memory task and a set of neurocognitive tests two to six months post-trauma. A group of non trauma-exposed youths (N = 36, Mage = 13.9, 27 female) were compared on narrative and neurocognitive tasks. Results indicated that trauma memories in youth with, versus without, PTSD were more sensory-laden, temporally disrupted, difficult to verbally access, and formed a more 'central' part of their identity. Greater differences were observed for self-reported memory characteristics compared to narrative characteristics. No between group differences in neurocognitive function were observed. Self-reported trauma memory characteristics highlight an important factor in the aetiology of PTSD. The observed lack of significant differences in neurocognitive ability potentially suggests that cognitive factors represent a more relevant treatment target than neurocognitive factors in single-event PTSD. Further research to understand the cognitive factors represented by self-reported trauma memory characteristics is recommended.
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Mirabolfathi V, Choobin MH, Moradi AR, Sanambari F, Naeini S, Mahdavi M, Hitchcock C. Improving access to psychological intervention in low-middle income settings: Results from a waitlist-controlled, proof-of-concept trial of the MemFlex intervention for trauma-exposed Afghan youth. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2024. [PMID: 38736135 DOI: 10.1111/bjc.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/18/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Low-intensity interventions targeting a range of mental health issues offer a scalable approach for young trauma survivors in low-middle income countries. AIMS Here, we present results from a proof-of-concept, randomized, waitlist-controlled trial evaluating MemFlex, an autobiographical memory-based intervention, for trauma-exposed Afghan youth residing in Iran. MemFlex seeks to reduce the negative and overgeneral memory biases which maintain and predict poor mental health. MATERIALS AND METHODS Young people aged 12-18 years (N = 40) with parents who had experienced forced migration from Afghanistan were recruited from high schools in Karaj City in Iran. All had experienced a traumatic event in the last year. Participants were randomized to receive four weeks of a group-based delivery of MemFlex or Waitlist. Our primary cognitive outcome was autobiographical memory flexibility, that is, the ability to deliberately retrieve any memory type on demand. Primary clinical outcome was emotional distress, measured on the Farsi version of the Hopkins Symptom Checklist. RESULTS Results indicated that MemFlex participants demonstrated large effect sizes for pre-to-post improvement in memory flexibility (d = 2.04) and emotional distress (d = 1.23). These improvements were significantly larger than Waitlist (ds < .49), and were maintained at three-month follow-up. DISCUSSION Positive benefits were observed for completion of MemFlex, and future comparison against an active intervention appears warranted. CONCLUSION Further evaluation of MemFlex in this context may offer a low-cost, and low-resource intervention to improve access to psychological intervention for young migrants in low-middle income countries.
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Hitchcock C, Funk J, Cummins R, Patel SD, Catarino A, Takano K, Dalgleish T, Ewbank M. A deep learning quantification of patient specificity as a predictor of session attendance and treatment response to internet-enabled cognitive behavioural therapy for common mental health disorders. J Affect Disord 2024; 350:485-491. [PMID: 38244796 DOI: 10.1016/j.jad.2024.01.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 01/09/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Increasing an individual's ability to focus on concrete, specific detail, thus reducing the tendency toward overly broad, decontextualised generalisations about the self and world, is a target within cognitive behavioural therapy (CBT). However, empirical investigation of the impact of within-treatment specificity on treatment outcomes is scarce. We evaluated whether the specificity of patient dialogue predicted a) end-of-treatment symptoms and b) session completion for CBT for common mental health issues. METHODS This preregistered (https://osf.io/agr4t) study trained a deep learning model to score the specificity of patient dialogue in transcripts from 353,614 internet-enabled CBT sessions for common mental health disorders, delivered on behalf of UK NHS services. Data were from obtained from 65,030 participants (n = 47,308 female, n = 241 unstated) aged 18-94 years (M = 34.69, SD = 12.35). Depressive disorders were the most common (39.1 %) primary diagnosis. Primary outcome was end-of-treatment score on the Patient Health Questionnaire-9 (PHQ-9). Secondary outcome was number of sessions attended. RESULTS Linear mixed-effects models demonstrated that increased patient specificity significantly predicted lower post-treatment symptoms on the PHQ-9, although the size and direction of the effect varied depending on the type of therapeutic activity being completed. Effect sizes were consistently small. Higher patient specificity was associated with completing a greater number of sessions. LIMITATIONS We are unable to infer causation from our data. CONCLUSIONS Although effect sizes were small, an effect of specificity was observed across common mental health disorders. Further studies are needed to explore whether encouraging patient specificity during CBT may provide an enhancement of treatment attendance and treatment effects.
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Smith AJ, Bisby JA, Dercon Q, Bevan A, Kigar SL, Lynall ME, Dalgleish T, Hitchcock C, Nord CL. Hot metacognition: poorer metacognitive efficiency following acute but not traumatic stress. Transl Psychiatry 2024; 14:133. [PMID: 38438352 PMCID: PMC10912213 DOI: 10.1038/s41398-024-02840-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
Aberrations to metacognition-the ability to reflect on and evaluate self-performance-are a feature of poor mental health. Theoretical models of post-traumatic stress disorder propose that following severe stress or trauma, maladaptive metacognitive evaluations and appraisals of the event drive the development of symptoms. Empirical research is required in order to reveal whether disruptions to metacognition cause or contribute to symptom development in line with theoretical accounts, or are simply a consequence of ongoing psychopathology. In two experiments, using hierarchical Bayesian modelling of metacognition measured in a memory recognition task, we assessed whether distortions to metacognition occur at a state-level after an acute stress induction, and/or at a trait-level in a sample of individuals experiencing intrusive memories following traumatic stress. Results from experiment 1, an in-person laboratory-based experiment, demonstrated that heightened psychological responses to the stress induction were associated with poorer metacognitive efficiency, despite there being no overall change in metacognitive efficiency from pre- to post-stress (N = 27). Conversely, in experiment 2, an online experiment using the same metamemory task, we did not find evidence of metacognitive alterations in a transdiagnostic sample of patients with intrusive memory symptomatology following traumatic stress (N = 36, compared to 44 matched controls). Our results indicate a relationship between state-level psychological responses to stress and metacognitive alterations. The lack of evidence for pre- to post-stress differences in metamemory illustrates the importance for future studies to reveal the direction of this relationship, and consequently the duration of stress-associated metacognitive impairments and their impact on mental health.
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Vainre M, Dalgleish T, Watson P, Haag C, Dercon Q, Galante J, Hitchcock C. Work Engagement and Well-being Study (SWELL): a randomised controlled feasibility trial evaluating the effects of mindfulness versus light physical exercise at work. BMJ MENTAL HEALTH 2024; 27:e300885. [PMID: 38423582 PMCID: PMC10910646 DOI: 10.1136/bmjment-2023-300885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Mindfulness-based programmes (MBPs) are increasingly offered at work, often in online self-guided format. However, the evidence on MBPs' effect on work performance (WP) is inconsistent. OBJECTIVE This pragmatic randomised controlled feasibility trial assessed procedural uncertainties, intervention acceptability and preliminary effect sizes of an MBP on WP, relative to an alternative intervention. METHODS 241 employees from eight employers were randomised (1:1) to complete a 4-week, self-guided, online MBP or a light physical exercise programme (LE)(active control). Feasibility and acceptability measures were of primary interest. WP at postintervention (PostInt) was the primary outcome for preliminary assessment of effect sizes. Secondary outcomes assessed mental health (MH) and cognitive processes hypothesised to be targeted by the MBP. Outcomes were collected at baseline, PostInt and 12-week follow-up (12wFUP). Prospective trial protocol: NCT04631302. FINDINGS 87% of randomised participants started the course. Courses had high acceptability. Retention rates were typical for online trials (64% PostInt; 30% 12wFUP). MBP, compared with the LE control, offered negligible benefits for WP (PostInt (d=0.06, 95% CI -0.19 to 0.32); 12wFUP (d=0.02, 95% CI -0.30 to 0.26)). Both interventions improved MH outcomes (ds=-0.40 to 0.58, 95% CI -0.32 to 0.18); between-group differences were small (ds=-0.09 to 0.04, 95% CI -0.15 to 0.17). CONCLUSION The trial is feasible; interventions are acceptable. Results provide little support for a later phase trial comparing an MBP to a light exercise control. To inform future trials, we summarise procedural challenges. CLINICAL IMPLICATIONS Results suggest MBPs are unlikely to improve WP relative to light physical exercise. Although the MBP improved MH, other active interventions may be just as efficacious. TRIAL REGISTRATION NUMBER NCT04631302.
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Kullar M, Carter S, Hitchcock C, Whittaker S, Wright AGC, Dalgleish T. Patterns of emotion-network dynamics are orthogonal to mood disorder status: An experience sampling investigation. Emotion 2024; 24:116-129. [PMID: 37227830 DOI: 10.1037/emo0001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Individuals differ markedly in how they experience the ebb and flow of emotions. In this study, we used daily experience sampling to examine whether these differences reflect the nature and presence of mood disorders or whether they can better be characterized as distinct dynamic emotion profiles that cut-across diagnostic boundaries. We followed 105 individuals in 2019-2020 with diagnoses of major depression, remitted major depression, bipolar disorder, or no history of disorder, over 14 days (n = 6,543 experience-sampling assessments). We applied group iterative multiple model estimation, using both diagnosis-based and data-driven methods to investigate similarities in unfolding within-person emotion-network time-courses. Results did not support diagnosis-based subgroupings but rather revealed two significant data-driven subgroups based on dynamic emotion patterns. These data-driven subgroups did not significantly differ in terms of clinical features or demographics, but did differ on key emotion metrics-instability, granularity, and inertia. These data-driven subgroupings, agnostic to diagnostic status, provide insights into the nature of idiographic emotion-network dynamics that cut-across clinical diagnostic divisions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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de Haan A, Meiser-Stedman R, Landolt MA, Kuhn I, Black MJ, Klaus K, Patel SD, Fisher DJ, Haag C, Ukoumunne OC, Jones BG, Flaiyah AM, Catani C, Dawson K, Bryant RA, de Roos C, Ertl V, Foa EB, Ford JD, Gilboa-Schechtman E, Tutus D, Hermenau K, Hecker T, Hultmann O, Axberg U, Jaberghaderi N, Jensen TK, Ormhaug SM, Kenardy J, Lindauer RJL, Diehle J, Murray LK, Kane JC, Peltonen K, Kangaslampi S, Robjant K, Koebach A, Rosner R, Rossouw J, Smith P, Tonge BJ, Hitchcock C, Dalgleish T. Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:28-39. [PMID: 37980918 DOI: 10.1016/s2352-4642(23)00253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators. METHODS This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954. FINDINGS We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms. INTERPRETATION This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress. FUNDING Swiss National Science Foundation.
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Dercon Q, Mehrhof SZ, Sandhu TR, Hitchcock C, Lawson RP, Pizzagalli DA, Dalgleish T, Nord CL. A core component of psychological therapy causes adaptive changes in computational learning mechanisms. Psychol Med 2024; 54:327-337. [PMID: 37288530 DOI: 10.1017/s0033291723001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cognitive distancing is an emotion regulation strategy commonly used in psychological treatment of various mental health disorders, but its therapeutic mechanisms are unknown. METHODS 935 participants completed an online reinforcement learning task involving choices between pairs of symbols with differing reward contingencies. Half (49.1%) of the sample was randomised to a cognitive self-distancing intervention and were trained to regulate or 'take a step back' from their emotional response to feedback throughout. Established computational (Q-learning) models were then fit to individuals' choices to derive reinforcement learning parameters capturing clarity of choice values (inverse temperature) and their sensitivity to positive and negative feedback (learning rates). RESULTS Cognitive distancing improved task performance, including when participants were later tested on novel combinations of symbols without feedback. Group differences in computational model-derived parameters revealed that cognitive distancing resulted in clearer representations of option values (estimated 0.17 higher inverse temperatures). Simultaneously, distancing caused increased sensitivity to negative feedback (estimated 19% higher loss learning rates). Exploratory analyses suggested this resulted from an evolving shift in strategy by distanced participants: initially, choices were more determined by expected value differences between symbols, but as the task progressed, they became more sensitive to negative feedback, with evidence for a difference strongest by the end of training. CONCLUSIONS Adaptive effects on the computations that underlie learning from reward and loss may explain the therapeutic benefits of cognitive distancing. Over time and with practice, cognitive distancing may improve symptoms of mental health disorders by promoting more effective engagement with negative information.
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Songco A, Patel SD, Dawes K, Rodrigues E, O'Leary C, Hitchcock C, Dalgleish T, Schweizer S. Affective working memory in depression. Emotion 2023; 23:1802-1807. [PMID: 36441997 PMCID: PMC10448741 DOI: 10.1037/emo0001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Depressed individuals show a wide range of difficulties in executive functioning (including working memory), which can be a significant burden on everyday mental processes. Theoretical models of depression have proposed these difficulties to be especially pronounced in affective contexts. However, evidence investigating affective working memory (WM) capacity in depressed individuals has shown mixed results. The preregistered study used a complex span task, which has been shown to be sensitive to difficulties with WM capacity in affective relative to neutral contexts in other clinical groups, to explore affective WM capacity in clinical depression. Affective WM capacity was compared between individuals with current depression (n = 24), individuals in remission from depression (n = 25), and healthy controls (n = 30). The results showed that, overall, WM capacity was more impaired in the context of negative distractor images, relative to neutral images. Furthermore, those with a lifetime history of depression (individuals with current depression and individuals remitted from depression), performed worse on the task, compared to healthy controls. However, there was no support for the greater disruption of WM capacity in affective compared to neutral contexts in those with a lifetime history of depression. These findings' implications for current models of depression are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Marsh LC, Patel SD, Smith AJ, So M, Armstrong H, Elliott R, Watkins E, Moulds M, Dalgleish T, Hitchcock C. From basic science to clinical practice: Can cognitive behavioural therapy tasks be augmented with enhanced episodic specificity? Behav Res Ther 2023; 167:104352. [PMID: 37331240 DOI: 10.1016/j.brat.2023.104352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/28/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023]
Abstract
Individuals with depression typically remember their past in a generalised manner, at the cost of retrieving specific event memories. This may impair engagement with cognitive behavioural therapy (CBT) tasks that use concrete episodic information to challenge maladaptive beliefs, potentially limiting their therapeutic benefit. Study 1 demonstrated that an episodic specificity induction increased detail and specificity of autobiographical memory in people with major depression, relative to control conditions (N = 88). We therefore examined whether the induction enhanced the efficacy of CBT tasks that depend on episodic memory - cognitive reappraisal (Study 2, N = 30), evidence gathering (Study 2, N = 30), and planning behavioural experiments (Study 3a, N = 30). Across all three tasks, there were no significant differences in emotion- or belief-change between the specificity and control conditions. Although the induction temporarily enhanced specificity in depressed individuals, it did not significantly augment the efficacy of CBT tasks theorised to benefit from the use of specific mnemonic information.
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Follett D, Hitchcock C, Dalgleish T, Stretton J. Reduced social risk-taking in depression. JOURNAL OF PSYCHOPATHOLOGY AND CLINICAL SCIENCE 2023; 132:156-164. [PMID: 36808959 PMCID: PMC9940639 DOI: 10.1037/abn0000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Evolutionary models of depression posit that depressed mood represents an adaptive response to unacceptably low social status, motivating the inhibition of social risk-taking in favor of submissive behaviors which reduce the likelihood of social exclusion. We tested the hypothesis of reduced social risk taking using a novel adaptation of the Balloon Analogue Risk Task (BART) in participants with major depressive disorder (MDD; n = 27) and never-depressed comparison participants (n = 35). The BART requires participants to pump up virtual balloons. The more the balloon is pumped up, the more money a participant gains on that trial. However, more pumps also increase the risk the balloon will burst such that all money is lost. Prior to performing the BART, participants took part in a team induction in small groups in order to prime social-group membership. Participants then completed two conditions of the BART: an Individual condition where they risked only their own money, and a Social condition, where they risked the money of their social group. The groups did not differ in their performance in the individual condition (Cohen's d = 0.07). However, the MDD group risked fewer pumps in the Social condition than the never-depressed group (d = 0.57). The study supports the notion of an aversion to social risk-taking in depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Patel SD, Esteves CV, So M, Dalgleish T, Hitchcock C. More than meets the eye: emotional stimuli enhance boundary extension effects for both depressed and never-depressed individuals. Cogn Emot 2022; 37:128-136. [PMID: 36537807 DOI: 10.1080/02699931.2022.2155622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Boundary extension is a memory phenomenon in which an individual reports seeing more of a scene than they actually did. We provide the first examination of boundary extension in individuals diagnosed with depression, hypothesising that an overemphasis on pre-existing schema may enhance boundary extension effects on emotional photographs. The relationship between boundary extension and overgeneralisation in autobiographical memory was also explored. Individuals with (n = 42) and without (n = 41) Major Depressive Disorder completed a camera paradigm task utilising positive, negative, and neutral stimuli. Across all participants, positive (d = 0.37) and negative (d = 0.66) stimuli were extended more than neutral stimuli. This effect did not differ between depressed and never-depressed participants. Across all participants, images containing objects were extended more than images containing faces. An association was also evident between extension effects in memory for perceptual space and extensions of autobiographical memory across time.
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Schweizer S, Auer T, Hitchcock C, Lee-Carbon L, Rodrigues E, Dalgleish T. Affective Control Training (AffeCT) reduces negative affect in depressed individuals. J Affect Disord 2022; 313:167-176. [PMID: 35792299 DOI: 10.1016/j.jad.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 06/09/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022]
Abstract
Depression is the leading cause of disability worldwide, with prevalence rates rising. Despite the scale of the problem, available pharmacological and psychological interventions only have limited efficacy. The National Institute of Health's Science of Behaviour Change framework proposes to address this issue by capitalising on insights from basic science to identify mechanisms that can be targeted by novel interventions. The current study evaluated the potential of a computerized programme aimed at improving affective control, a mechanistic target involved in both risk and maintenance of depression. In a first phase the cognitive profiles of 48 depressed individuals (mean age: 39 years, 75 % female) were compared to cognitive functioning in 16 never-depressed individuals (mean age: 31 years, 56 % female). The sole index of functioning that differed between diagnostic groups was reaction time across negative and positively valanced trials on an affective Stroop task (d = 0.58). This index was then used to evaluate an affective control training (AffeCT) against a placebo training. Results showed no significant changes on tasks that showed no differences with never-depressed individuals in Phase I. However, compared to placebo training, AffeCT led to significantly greater improvement in the target index, affective Stroop performance (d = 1.17). Importantly, AffeCT led to greater reductions in negative affect as measured by the Positive Affect and Negative Affect Schedule compared to the placebo training (d = 0.98). This proof-of-concept study shows promising benefits of AffeCT on depressed individuals' affect, but not depressive symptoms. It further supports the utility of the Science of Behaviour Change framework, highlighting the need for determining meaningful assays of target mechanisms when evaluating novel interventions.
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Maercker A, Cloitre M, Bachem R, Schlumpf YR, Khoury B, Hitchcock C, Bohus M. Complex post-traumatic stress disorder. Lancet 2022; 400:60-72. [PMID: 35780794 DOI: 10.1016/s0140-6736(22)00821-2] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/21/2022]
Abstract
Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Complex PTSD is characterised by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships. Complex PTSD has been adopted as a new diagnosis in the ICD-11. Individuals with complex PTSD typically have sustained or multiple exposures to trauma, such as childhood abuse and domestic or community violence. The disorder has a 1-8% population prevalence and up to 50% prevalence in mental health facilities. Progress in diagnostics, assessment, and differentiation from post-traumatic stress disorder and borderline personality disorder is reported, along with assessment and treatment of children and adolescents. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions.
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Vainre M, Galante J, Watson P, Dalgleish T, Hitchcock C. Protocol for the Work Engagement and Well-being Study (SWELL): a randomised controlled feasibility trial evaluating the effects of mindfulness versus light physical exercise at work. BMJ Open 2022; 12:e050951. [PMID: 35414541 PMCID: PMC9006806 DOI: 10.1136/bmjopen-2021-050951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Mental ill health is a major cause of disability. Workplaces are attractive for preventative interventions since most adults work; meanwhile, employers are interested in improving employees' well-being and productivity. Mindfulness-based programmes are increasingly popular in occupational settings. However, there is inconsistent evidence whether mindfulness interventions improve work performance and how effective mindfulness-based programmes are, compared with other interventions, in preventing mental ill health. METHODS AND ANALYSIS In this online randomised controlled feasibility trial, an anticipated 240 employees will be randomised to either a 4-week light physical exercise course or a mindfulness course of the same duration (1:1 allocation). The primary outcome is work performance, measured using the Work Role Functioning Questionnaire. We aim to evaluate the acceptability, feasibility and procedural uncertainties of a randomised controlled trial in a workplace, calculate an effect size estimate to inform power calculations for a larger trial, and explore whether improved executive function and/or enhanced mental health could be potential mechanisms underlying the effect of mindfulness on work performance. Outcomes will be collected at baseline, postintervention and 12-week follow-up. ETHICS AND DISSEMINATION Approval has been obtained from Cambridge Psychology Research Ethics Committee. (PRE.2020072). Results will be published in peer-reviewed journals. A lay summary will be disseminated to a wider audience including participating employers. TRIAL REGISTRATION NUMBER NCT04631302.
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Hitchcock C, Rudokaite J, Haag C, Patel SD, Smith AJ, Kuhn I, Jermann F, Ma SH, Kuyken W, Williams JM, Watkins E, Bockting CLH, Crane C, Fisher D, Dalgleish T. Autobiographical memory style and clinical outcomes following mindfulness-based cognitive therapy (MBCT): An individual patient data meta-analysis. Behav Res Ther 2022; 151:104048. [PMID: 35121385 PMCID: PMC7613018 DOI: 10.1016/j.brat.2022.104048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 11/02/2022]
Abstract
The ability to retrieve specific, single-incident autobiographical memories has been consistently posited as a predictor of recurrent depression. Elucidating the role of autobiographical memory specificity in patient-response to depressive treatments may improve treatment efficacy and facilitate use of science-driven interventions. We used recent methodological advances in individual patient data meta-analysis to determine a) whether memory specificity is improved following mindfulness-based cognitive therapy (MBCT), relative to control interventions, and b) whether pre-treatment memory specificity moderates treatment response. All bar one study evaluated MBCT for relapse prevention for depression. Our initial analysis therefore focussed on MBCT datasets only(n = 708), then were repeated including the additional dataset(n = 880). Memory specificity did not significantly differ from baseline to post-treatment for either MBCT and Control interventions. There was no evidence that baseline memory specificity predicted treatment response in terms of symptom-levels, or risk of relapse. Findings raise important questions regarding the role of memory specificity in depressive treatments.
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Hitchcock C, Goodall B, Wright IM, Boyle A, Johnston D, Dunning D, Gillard J, Griffiths K, Humphrey A, McKinnon A, Panesar IK, Werner-Seidler A, Watson P, Smith P, Meiser-Stedman R, Dalgleish T. The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds. J Child Psychol Psychiatry 2022; 63:58-67. [PMID: 34128219 DOI: 10.1111/jcpp.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC. METHOD Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC. RESULTS In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures. CONCLUSIONS The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.
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Gillard JA, Gormley S, Griffiths K, Hitchcock C, Dalgleish T, Stretton J. Converging evidence for enduring perceptions of low social status in individuals in remission from depression. J Affect Disord 2021; 294:661-670. [PMID: 34333174 PMCID: PMC8411663 DOI: 10.1016/j.jad.2021.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND The risk of depressive relapse and recurrence is associated with social risk factors that may be amplified by a submissive socio-cognitive profile. METHODS In Study 1 we aimed to identify perceptions of low social status in a community sample (N = 613) with a self-reported history of mental health difficulties (n = 232) and, more specifically in Study 2 (N = 122), in individuals in clinical remission from depression (n = 18), relative to a never-depressed control group (n = 64), and relative to a group experiencing a current depressive episode (n = 40). RESULTS In Study 1, a total of 225 of the 232 participants in the self-reported mental health difficulties group opted to provide further information regarding their mental health history, of whom 153 (68%) reported a history of anxiety, 168 (74.7%) reported a history of depression, and 13 (5.8%) reported an unspecified mental health history. Elevated depressive symptoms were associated with perceptions of low social status which significantly differed between individuals with and without a self-reported history of mental health difficulties. In Study 2 we found enduring perceptions of low social status in remitted depressed individuals. LIMITATIONS We were unable to discern between historical or current clinical diagnosis in the community sample of Study 1, as we were reliant on self-report. We were unable to explore the effects of medication or causal relationships between depressive symptoms and social status as the studies were cross-sectional in nature. CONCLUSIONS These findings suggest that evolutionarily rooted socio-cognitive profiles could impact affiliative processes and may confer increased vulnerability to future depressive episodes.
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Hitchcock C, Brown RL, Cobham VE. Validation of the Child version of the Perseverative Thinking Questionnaire of repetitive negative thinking in young people with diagnosed depressive and anxiety disorders. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 61:242-254. [PMID: 34617301 PMCID: PMC9292182 DOI: 10.1111/bjc.12336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/28/2021] [Indexed: 12/02/2022]
Abstract
This paper sought to provide the first validation of a transdiagnostic measure of repetitive negative thinking – the Perseverative Thinking Questionnaire‐Child version (PTQ‐C) – in young people diagnosed with anxiety and depressive disorders. Participants (N = 114) were 11‐ to 17‐year‐olds with complex and comorbid presentations seeking treatment through Child and Adolescent Mental Health Services. Confirmatory factor analyses best supported a three‐factor model for the PTQ‐C; however, hypotheses of both perfect and close fit were rejected, and a subsequent bifactor model suggested minimal unique variance for each subscale. Results demonstrated good internal consistency, convergent validity and divergent validity for the total score and three PTQ‐S subscales: core characteristics, perceived unproductiveness, and consumed mental capacity of negative repetitive thinking. PTQ‐C scores did not account for additional variance in anxiety symptoms once worry was considered, indicating that retention of a content‐specific measure may be warranted in clinical samples. Findings emphasize the importance of validating clinically relevant measures which were developed with subclinical populations in samples with diagnosed mental health disorders.
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Hitchcock C, Goodall B, Sharples O, Meiser-Stedman R, Watson P, Ford T, Dalgleish T. Population Prevalence of the Posttraumatic Stress Disorder Subtype for Young Children in Nationwide Surveys of the British General Population and of Children in Care. J Am Acad Child Adolesc Psychiatry 2021; 60:1278-1287.e3. [PMID: 33667605 PMCID: PMC7614479 DOI: 10.1016/j.jaac.2020.12.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/12/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a debilitating condition that when left untreated can have severe lifelong consequences for psychological, social, and occupational functioning. Initial conceptualizations of PTSD were centered on adult presentations. However, the instantiation of developmentally appropriate PTSD in young children (PTSD-YC) criteria, tailored to preschool (6 years old and younger) children, represents an important step toward identifying more young children experiencing distress. This study explored population-level prevalence of PTSD-YC indexed via an alternative algorithm for DSM-IV PTSD (AA-PTSD). METHOD Representative population data were used to test whether application of AA-PTSD criteria, relative to the DSM-IV PTSD algorithm, increased identification of 5- to 6-year-old children with clinical needs in both the general population (n = 3,202) and among looked after children (ie, in Britain, foster children are called looked after children [more commonly referred to as children in care].) (n = 137), in whom the risk of mental health issues is greater. RESULTS Notably, no 5- to 6-year-old children in the general population sample were diagnosed with PTSD using adult-based DSM-IV criteria. In contrast, AA-PTSD prevalence was 0.4% overall, rising to 5.4% in trauma-exposed children. In looked after children, overall PTSD prevalence rose from 1.2% when applying adult-based DSM-IV criteria to 14% when using AA-PTSD criteria. Of trauma-exposed looked after children, 2.7% met criteria for DSM-IV PTSD compared with 57.0% when applying AA-PTSD criteria. In both samples, use of the alternative algorithm to index PTSD-YC criteria markedly increased identification of children experiencing functional impairment owing to symptoms. CONCLUSION Results demonstrate the utility of the PTSD-YC diagnosis beyond at-risk and treatment-seeking samples. Use of PTSD-YC criteria substantially improves identification of 5- to 6-year-old children burdened by PTSD at the population level.
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Moradi AR, Piltan M, Choobin MH, Azadfallah P, Watson P, Dalgleish T, Hitchcock C. Proof of Concept for the Autobiographical Memory Flexibility (MemFlex) Intervention for Posttraumatic Stress Disorder. Clin Psychol Sci 2021; 9:686-698. [PMID: 34354873 PMCID: PMC8278548 DOI: 10.1177/2167702620982576] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 01/18/2023]
Abstract
Autobiographical memory distortions are a key feature of posttraumatic stress disorder (PTSD). In this proof-of-concept randomized controlled trial (N = 43), we evaluated an autobiographical memory flexibility intervention, MemFlex. We aimed to determine whether the mechanism-focused intervention, which aims to improve autobiographical memory processes, may also affect other cognitive predictors of PTSD and potentially reduce PTSD symptoms in Iranian trauma survivors diagnosed with PTSD. Results indicated significant, moderate to large between-groups effect sizes in favor of MemFlex, relative to wait-list control, for the targeted cognitive mechanism of autobiographical memory flexibility and PTSD symptoms. A large, significant effect was also observed on maladaptive posttraumatic cognitions-a strong predictor of PTSD prognosis, which is a key target of high-intensity cognitive therapies for PTSD. Findings support future completion of a scaled-up trial to evaluate treatment efficacy of MemFlex for PTSD to determine whether MemFlex may offer a culturally adaptive, low-cost, low-intensity intervention able to improve cognitive mechanisms of PTSD.
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Hitchcock C, Smith AJ, Elliott R, O'Leary C, Gormley S, Parker J, Patel SD, Esteves CV, Rodrigues E, Hammond E, Watson P, Werner-Seidler A, Dalgleish T. A randomized, controlled proof-of-concept trial evaluating durable effects of memory flexibility training (MemFlex) on autobiographical memory distortions and on relapse of recurrent major depressive disorder over 12 months. Behav Res Ther 2021; 140:103835. [PMID: 33691266 PMCID: PMC8047774 DOI: 10.1016/j.brat.2021.103835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/24/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022]
Abstract
Low-intensity psychological interventions that target cognitive risk factors for depressive relapse may improve access to relapse prevention programs and thereby reduce subsequent risk. This study provides the first evaluation of an autobiographical memory-based intervention for relapse prevention, to establish whether memory-training programs that are efficacious for acute depression may also aid those currently in remission. We also provide the longest follow-up to-date of the effects of autobiographical memory training on autobiographical memory processes themselves. This pre-registered randomized-controlled proof-of-concept trial (N = 74) compared an autobiographical Memory Flexibility (MemFlex) intervention to Psychoeducation about cognitive-behavioral mechanisms which maintain depression. Both interventions were primarily self-guided, and delivered via paper workbooks completed over four weeks. The key cognitive outcome was ability to retrieve and alternate between specific and general autobiographical memories. Co-primary clinical outcomes were time until depressive relapse and depression-free days in the twelve-months following intervention. Results indicated a small-moderate effect size (d = 0.35) in favor of MemFlex for the cognitive outcome. A small Hazard Ratio (1.08) was observed for time until depressive relapse, along with a negligible effect size for depression-free days (d = 0.11). Although MemFlex produced long-term improvement in memory retrieval skills, there was little support for MemFlex as a relapse prevention program for depression.
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