The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review

Patterns of cognitive-emotional change after cognitive-behavioural treatment in emotional disorders: A 12-month longitudinal cluster analysis

INTRODUCTION

The aim of this study was to use cluster analysis based on the trajectory of five cognitive-emotional processes (worry, rumination, metacognition, cognitive reappraisal and expressive suppression) over time to explore differences in clinical and performance variables in primary care patients with emotional symptoms.

METHODS

We compared the effect of adding transdiagnostic cognitive-behavioural therapy (TD-CBT) to treatment as usual (TAU) according to cluster membership and sought to determine the variables that predicted cluster membership. 732 participants completed scales about cognitive-emotional processes, anxiety and depressive symptoms, functioning, and quality of life (QoL) at baseline, posttreatment, and at 12 months. Longitudinal cluster analysis and logistic regression analyses were carried out.

RESULTS

A two-cluster solution was chosen as the best fit, named as "less" or "more" improvement in cognitive-emotional processes. Individuals who achieved more improvement in cognitive-emotional processes showed lower emotional symptoms and better QoL and functioning at all three time points. TAU+TD-CBT, income level, QoL and anxiety symptoms were significant predictors of cluster membership.

CONCLUSIONS

These results underscore the value of adding TD-CBT to reduce maladaptive cognitive-emotional regulation strategies. These findings highlight the importance of the processes of change in therapy and demonstrate the relevance of the patient's cognitive-emotional profile in improving treatment outcomes.

Do Patient's Interpersonal Problems Improve Following Metacognitive Therapy? A Systematic Review and Meta-Analysis

Metacognitive therapy (MCT) aims to modify dysfunctional metacognitions that are thought to be universal determinants of emotional distress and psychological dysfunction more generally. MCT is an effective treatment for emotional distress symptoms, but less is known about its effect for other types of psychological problems. Interpersonal problems are common in psychological disorders and should be improved following psychotherapy. Therefore, we conducted a systematic review and meta-analysis of trials on the effects associated with MCT for interpersonal problems among adults with mental health disorders published until 15 November 2023 using PubMed, Cochrane Library and PsycNet. Trials with a minimum of 10 participants were included. A total of six studies based on five trials reported on the effectiveness of MCT for interpersonal problems and met our inclusion criteria. Two trials evaluated MCT for patients with major depressive disorders, two for patients with anxiety disorders and one for borderline personality disorder. Three of the trials were randomized controlled trials. Four of the trials reported follow-up data but varied in their time-points. The within-group effect size estimate from pretreatment to posttreatment across five trials was large (g = 0.865, 95% CI [0.512-1.218]). Our results indicate that MCT is an effective treatment for improving interpersonal problems in individuals with common mental disorders, even though the treatment is short and primarily concern improving mental regulation through modifying metacognitions. While this finding is in line with metacognitive theory, more trials evaluating personality and interpersonal functioning are needed to draw firm conclusions.

The Role of Metacognition in the Prediction of Depressive and Anxiety Symptoms in Chronically Ill Patients

INTRODUCTION

Cancer, diabetes, and heart diseases are frequent causes of depression and anxiety. The study explored the metacognitive beliefs manifested by chronically ill patients and the presence of depressive or anxiety symptoms and the predictive role of metacognition in both.

METHODS

A total of 254 chronically ill patients participated in the study. The Metacognitive Questionnaire was used to measure the patients' metacognitive beliefs, whereas the Hospital Anxiety and Depression Scale was applied to evaluate their psychopathological symptoms. A correlation analysis was performed to explore the relationships between metacognition and psychopathological symptoms. Regression analyses were conducted to examine the predictive role of metacognition in anxiety and depression.

RESULTS

The Negative Beliefs about Uncontrollability and Danger scale correlated with both anxiety and depression scales, and the Cognitive Confidence scale correlated with the depression scale. Linear regression analyses indicated that metacognitive beliefs were responsible for 32.2% of the variance of anxiety symptoms among all the chronically ill. Metacognitive beliefs accounted for 48.8% of the variance in anxiety symptoms and 36.6% in depressive symptoms among diabetes patients.

CONCLUSIONS

There are specific correlations between psychopathological symptoms and metacognition among chronically ill patients. Metacognitions have a moderate role in developing and sustaining anxiety and depressive symptoms.

Efficacy and moderators of metacognitive training for depression in older adults (MCT-Silver): A randomized controlled trial

BACKGROUND

Up to 79 % of older adults with depression do not receive treatments commensurate with guideline recommendations. Metacognitive Training-Silver (MCT-Silver) is a low-intensity group training, which aims to reduce depressive symptoms by targeting (meta)cognitive beliefs.

METHODS

A randomized controlled trial comparing MCT-Silver (n = 41) to cognitive remediation (n = 39) was conducted with older adults with major depressive disorder and/or dysthymia. Clinician-rated depression (Hamilton Depression Rating Scale [HDRS, primary outcome]), self-reported depression (Beck Depression Inventory-II [BDI-II]), negative cognitive beliefs, positive metacognitive beliefs, rumination, health status, quality of life, and neurocognitive functioning were assessed at baseline, eight weeks (post) and three months (follow-up).

RESULTS

Both groups demonstrated moderate to large reductions in depression. No superior effects of MCT-Silver on clinician-rated depression (HDRS) were detected. MCT-Silver led to greater reductions in self-reported depression and rumination at post- and follow-up. Despite this, scores at post- and follow-up assessments were similar for both groups. MCT-Silver's effect on depressive symptoms was moderated by baseline rumination, positive metacognitive beliefs and previous treatment experience. MCT-Silver was evaluated as superior according to patient appraisals.

LIMITATIONS

Conclusions are limited by divergent findings on measures of depression and that the study was conducted during the COVID-19 pandemic.

CONCLUSIONS

Whereas no superior effect of MCT-Silver was found for the primary outcome, there was a significant effect of MCT-Silver for self-reported depression and rumination. Patients endorsing rumination and positive metacognitive beliefs as well as those without previous psychological treatment may benefit more from MCT-Silver.

The Psychological Symptoms and Their Relationship to the Quality of Life Among Dementia Patients Caregivers

The study aims to identify psychological symptoms (depression and anxiety) and their relationship to the quality of life among dementia patients' caregivers, and whether there are differences in the level of each of them due to the gender variable. The study follows the correlational approach, with a sample of 174 dementia patients' caregivers. To pursue the analysis, the study uses 3 measurement tools: anxiety, depression, and quality of life. The results show that the level of depression, anxiety, and quality of life among dementia patients' caregivers is moderate. It also finds that there is a positive relationship between anxiety and depression, and there is a negative relationship between quality of life and anxiety and depression. There are no differences in the level of depression and anxiety due to gender, as the study finds female caregivers to have a higher level of quality of life.

Efficacy of contextual therapies in perinatal depression and anxiety: A systematic review and meta-analysis

BACKGROUND

There are previous meta-analyses on the efficacy of cognitive behavioral therapy or mindfulness-based therapies in the perinatal period, but no previous review has focused on contextual therapies as a whole. The aim of this study was to carry out a systematic review and meta-analysis of the efficacy of contextual therapies on depressive and anxious symptoms in women in the perinatal period.

METHODS

A systematic search for randomized clinical trials has been carried out in the PUBMED, CINAHL, Psyc-INFO and Cochrane Library search engines. For the quantitative synthesis, the Morris effect size measure has been used.

RESULTS

A total of 34 RCTs have been found, of which 30 have been used for meta-analysis. The mean effect size of the studies on depression scores was dppc2 = -0.81 (95% CI = -1.12 to -0.50), while it was dppc2 = -1.04 (95% CI = -1.54 to -0.53) in the case of studies on anxiety scores. These effect sizes decreased to medium effect sizes when corrected for publication bias.

LIMITATIONS

The main limitations are the quality of the included studies, publication bias, and the limited number of studies on contextual therapies other than mindfulness-based therapies.

CONCLUSIONS

In conclusion, this systematic review found a large number of efficacy studies on mindfulness-based therapies and a small number of studies on the other contextual therapies. The effect sizes found are consistent with previous meta-analyses in the perinatal period.

Attention training technique delivered in groups as treatment for anxiety and depression in patients with coronary heart disease: study protocol for a waiting-list randomized controlled trial

Introduction

Clinically significant symptoms of depression and anxiety in coronary heart disease (CHD) patients are common and associated with adverse outcomes. Psychological treatments have shown limited effectiveness and more effective treatments have been requested. Attention training technique (ATT), a component of metacognitive therapy, can potentially be effective as a stand-alone treatment for anxiety and depression. In an open study, ATT delivered face-to-face in a group format was feasible and potentially effective for improving depression and anxiety symptoms in CHD patients. The next progressive step is to test the effectiveness of ATT in a randomized controlled trial. This paper describes the methodology of this trial.

Methods

ATT-CHD is a randomized wait-list (WL) controlled study. Eligible CHD patients from two hospitals with Hospital Anxiety and Depression Scale (HADS)-Anxiety and/or HADS-Depression subscales scores ≥8 will be randomized into ATT (n = 32) or WL control (n = 32). After 6-8 weeks, WL patients will be allocated to ATT. Participants will be evaluated pre-, mid- and post-treatment, and at 6-months follow-up using changes in HADS as primary outcome. Secondary outcomes will be changes in psychiatric disorders, rumination, worry, type D-personality, metacognitions, insomnia, quality of life, and C-Reactive protein (CRP).

Discussion

To our knowledge, this will be the first WL-controlled randomized study testing the effectiveness of group-based ATT as treatment of symptoms of anxiety and depression in CHD patients. It will also explore correlations between changes in psychological distress and CRP. A qualitative analysis will reveal patients' experience with ATT including processes that may facilitate or serve as barriers to effectiveness. Recruitment into the study commenced in December 2022.

Ethics and dissemination

The Regional Committees for Medical and Health Research Ethics (REK), Norway has granted approval for the study (ID 52002). The trial results will be published in peer-reviewed journals. According to Norwegian legislation, the Norwegian Data Protection Authority, and the Committee of Ethics, we are not allowed to share original study data publicly.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05621408 pre-inclusion. There were no significant changes of methods or outcomes after study start.

Psychiatric disorders, rumination, and metacognitions in patients with type D personality and coronary heart disease

BACKGROUND

Little is known regarding the prevalence of psychiatric disorders in patients with both coronary heart disease (CHD) and type D personality, and whether these patients may benefit from psychotherapy that modifies metacognitive beliefs implicated in disorder maintenance. This study explored prevalence rates among these patients and associations between type D characteristics, rumination and metacognitions.

METHODS

Forty-seven consecutive patients with CHD who scored positive for type D personality were included in this pre-planned study. Participants underwent structured clinical interviews for mental and personality disorders and completed questionnaires assessing rumination and metacognitions.

RESULTS

Mean age was 53.8 (SD 8.1) years and 21.3% were female. At least one mood disorder or anxiety disorder was found in 70.2% and 61.7% of the patients. The most common disorders were major depressive disorder (59.6%), social phobia (40.4%), and generalized anxiety disorder (29.8%). At least one personality disorder was detected in 42.6%. Only 21% reported ongoing treatment with psychotropic medication whereas none had psychotherapy. Metacognitions and rumination were significantly associated with negative affectivity (0.53-0.72, p < .001) but not social inhibition.

CONCLUSION

Mood and anxiety disorders were highly prevalent and relatively untreated among these patients. Future studies should test the metacognitive model for type D personality.

Metacognitive beliefs and anxiety symptoms could serve as mediators between fear of missing out and gaming disorder in adolescents

Given the vulnerability to and prevalence of emotional problems and Internet gaming disorder (IGD) in adolescents, this study aimed to test the effects of fear of missing out (FoMO) on IGD and the mediating roles of metacognitive beliefs and anxiety symptoms based on the self-regulatory executive function (S-REF) model. At a Chinese high school, 283 participants (M_age = 16.89 years old; girls = 42.0%) with past-year gaming experience voluntarily completed an anonymous paper-and-pencil questionnaire. FoMO showed significant, positive associations with IGD, anxiety symptoms, and metacognitive beliefs. Results of path analysis showed a significant direct effect of FoMO on IGD, whereas anxiety symptoms mediated the relationship between FoMO and IGD. The indirect effects of FoMO on IGD via serial mediations of three negative metacognitive beliefs (i.e., negative beliefs about worry, low cognitive confidence, and beliefs regarding need for control) and anxiety symptoms were also statistically significant. These findings demonstrated that maladaptive metacognitive beliefs and anxiety are risk-enhancing mediators in the relationship between FoMO and IGD. Therefore, metacognitive therapy, particularly for regulating those three specific significant metacognitive beliefs, is recommended for treating IGD and anxiety, especially for those with higher levels of FoMO.

The psychometric properties of positive and negative beliefs about the rumination scale in Chinese undergraduates

BACKGROUND

Rumination, a transdiagnostic factor in different psychopathological conditions, is believed to be activated and sustained by dysfunctional metacognition. The Positive Beliefs about Rumination Scale (PBRS) and the Negative Beliefs about Rumination Scale (NBRS) have been used to measure the metacognitive beliefs of rumination and have been investigated in many cultural contexts. However, it remains unclear whether these scales can work as well for the Chinese population. Therefore, this study aimed to explore the psychometric properties of the Chinese versions of these scales and to test the metacognitive model of rumination for students with different levels of depression.

METHODS

The PBRS and NBRS were forward-backward translated into Mandarin. In total 1,025 college students were recruited to complete a battery of web-based questionnaires. Exploratory factor analysis, confirmatory factor analysis, and correlation analysis were used to test the structure, validity, and reliability of the two scales, as well as their item correlations with rumination.

RESULTS

A new two-factor structure of the PBRS (rather than the original one-factor model) and a new three-factor structure of the NBRS (rather than the original two-factor model) were extracted. The goodness-of-fit indices of these two factor models showed they had a good to very good fit with the data. The internal consistency and construct validity of PBRS and NBRS were also affirmed.

CONCLUSION

The Chinese versions of the PBRS and the NBRS were generally shown to be reliable and valid, but their newly extracted structures fit the Chinese college students better than their original structures. These new models of PBRS and NBRS are of value to be further explored in Chinese population.

Metacognition and insight dynamics exploration in borderline personality disorder: Exploring the underlying dynamics

Metacognition and Insight are related to hard-to-treat disorders and among them is Borderline Personality Disorder (BPD). We recruited 190 BPD patients and measured Insight, Metacognition, Impulsivity, and BPD traits. Results showed BPD's significant links with Insight and Metacognition. Metacognition significantly correlated with two Impulsivity dimensions, whereas Insight significantly correlated with most of them. Regressions analysis revealed a significant relationship between Insight and Metacognition on Impulsivity and Borderline traits. Mediation analysis proved the indirect effect of Metacognition/Insight on Borderline traits through Impulsivity at a significative level. Both seem relevant for research and therapeutic application in BPD following different dynamics even if the limitation of our study stands in its gender ratio and possible comorbidity issues. Urgency appears as a critical factor to assess, notably with Positive emotion-based impulsivity.

Cognitive processes associated with emotional disorders: implications for efficient psychological treatments

BACKGROUND

Emotional disorders (EDs) are the most prevalent worldwide. Despite psychotherapies are their treatment of choice, there are difficulties to apply them properly in mental health services. Since literature shows that cognitive processes are associated with anxiety and depressive symptoms, more information is needed in order to improve psychological treatments.

AIMS

To determine the relation between cognitive factors with specific and non-specific ED symptoms in order to promote the development of accurate psychological treatments.

METHODS

We analyzed the relation between rumination, worry, and metacognition with generalized anxiety, panic, and depression disorder symptoms from a clinical sample of 116 individuals through correlation and linear regression analyses.

RESULTS

Although each specific disorder had a closer link with a particular cognitive process, all general ED symptoms were associated with the three cognitive factors studied.

CONCLUSIONS

For "pure" disorders, targeting a concrete cognitive process might be an optimal therapeutic option. However, due to the high comorbidity among EDs, we support the dissemination of the transdiagnostic treatment approach in which all cognitive factors are taken into account.

A mobile-based aftercare intervention to increase self-esteem in inpatients diagnosed with depression: A randomized controlled trial

OBJECTIVE

In this randomized controlled trial, we investigated the effectiveness, side effects and user satisfaction of the self-help smartphone app "MCT & More" among inpatients with a diagnosis of depression after their discharge from a psychiatric hospital over a period of 4 weeks.

METHODS

A total of 159 inpatients were recruited in four German psychiatric hospitals three days before hospital discharge (intervention group: n = 79; treatment as usual: n = 80). Based on the vulnerability model (low self-esteem contributes to depression), self-esteem represented the primary outcome, quality of life and depressive symptoms the secondary outcomes.

RESULTS

Intention-to-treat analyzes showed no statistical significance for the primary and secondary outcome parameters, except for the subscale self-competence in favor of the intervention group (with a small effect size of d = 0.35), in the context of an exploratory approach (post hoc). The more positive the attitude toward mobile-based interventions and the more positive the treatment expectations, the more frequently the app was used (r = .35, p = .008; r = .34, p = .009).

CONCLUSION

Further symptom reduction could not be obtained. However, the results suggest that an effect on improvement in self-competence could be achieved by low-threshold aftercare programs. Future studies should include long-term assessments to examine the impact of mobile-based aftercare on relapse.Trial registration: DRKS00022559.

Metacognition vulnerabilities in time of crisis: Who to protect from suicidal risk?

INTRODUCTION

During stressful events, we are all trying to cope. We may not be equal depending on our emotional, psychological, and mental states. During the COVID-19 pandemic, we could try to avoid negative information processing and anxiogenics content to prevent unhealthy thinking processes. One of the processes we can observe regarding our way of thinking and its impact on our psychological well-being is Metacognition.

METHODS

We recruited 104 outpatients in 2018. In 2020, during the pandemic, we recruited 216 outpatients and 176 healthy controls. We assessed their level of metacognition with the MCQ30 scale together with Suicidal risk and Hopelessness.

RESULTS

All three groups showed significant differences, with the nonclinical sample having higher scores in MCQ30. Regression revealed the different profiles where Hopelessness was the only predictor for the clinical sample, whereas metacognition was an adjunctive predictor of suicidal risk for the nonclinical sample.

CONCLUSION

Our results showed that the COVID-19 crisis influenced metacognitive levels for the nonclinical sample but not for the clinical population. Moreover, Hopelessness predicted suicide risk for both populations, but Metacognition was also a predictive factor for the nonclinical sample. We conclude with the possible impact of preventive measures based on Metacognitive work that can be created out of these results.

Capacities for meta-cognition, social cognition, and alexithymia in postpartum depression

Postpartum depression (PPD), a female-specific disorder, is the most common medical complication associated with childbirth (10-20%). The pathological relevance of emotion processing, meta-cognition, alexithymia, and social cognition to PPD is unclear. We tested 25 mothers with PPD (mean age: 30.72 ± 5.76 years) and 25 healthy mothers (mean age: 32.03 ± 3.54 years) for alexithymia (Toronto Alexithymia Scale) and evaluated cognitive empathy (Faux Pas Test), affective empathy (Interpersonal Reactivity Index), meta-cognition (Meta-Cognitions Questionnaire), sociodemographic and clinical-psychometric characteristics and personality dimensions. Mothers with PPD showed higher levels of neuroticism and more anxiety-depressive characteristics. Their metacognitive abilities were significantly altered and they more often had alexithymia. Significant correlations between alexithymia and meta-cognition, trait anxiety, and neuroticism were found. Alexithymia, neurotic personality traits, and dysfunctional meta-cognition appear more frequently in PPD women than healthy women. Social cognition abilities were not significantly altered. Alexithymia and metacognitive distortions play important roles in the pathogenesis of PPD. Dysfunctional meta-cognition, neuroticism, and alexithymia may be risk factors that should be detected early in expectant mothers to prevent the development of PPD.

Metacognitions and brooding predict depressive symptoms in a community adolescent sample

Depressive symptoms are prevalent in adolescence, and girls have higher levels of depressive symptoms and depressive disorder than boys. Rumination and especially brooding, seem to be a central maintaining factor of depressive symptoms, where metacognitions about rumination play a prominent role in maintaining depressive rumination. There is a sex difference in adults in depressive disorder. The current investigation of a high school / community sample of adolescents aged 16-20 from Norway (N = 1198, 62.2% women) found that adolescent women had higher scores than men on all relevant measures: Depressive symptoms, negative and positive metacognitions, pondering, and brooding. A path model for predicting depressive symptoms showed that the major factors for both sexes were negative metacognitions and brooding. The predictors of depressive symptoms were invariant across sex and age groups, suggesting similar underlying mechanisms across these groups. The overall findings suggest that metacognitive therapy may be an efficient intervention for depressive symptoms among adolescents.

"Early Negative Memories, Humiliation and Defectiveness/Shame Schema: An Emotion-Focused Therapeutic Approach to Social Anxiety"

"Introduction: Recently emotion-focused therapy has developed as an additional approach and considers the role of primary emotions such as shame in the formation and persistence of SAD. Objectives: The purpose of this study was to investigate the theoretical model of emotion-focused therapy for SAD by considering the role of early negative memories, humiliation and the mediating role of self-defectiveness/shame schema in the etiology of SAD. Method: This cross-sectional descriptive study recruited a sample of 105 students, 44 males (41.9%) 61 females (58.1%), diagnosed with SAD by psychologists from Shahid Beheshti University Counseling Center. Participants ranging in age from 18 to 34 with a mean age of 23.1 years (SD=3.5) completed the Social Phobia Inventory, Humiliation Inventory, Early Life Experiences Scale, Defectiveness /Shame Schema subscale of the Young Schema Questionnaire-Short Form. Results: Data were analyzed using SmartPLS-SEM. The results showed that early childhood experiences and humiliation significantly predict SAD. Also, the indirect effects of the independent variables through defectiveness/shame schema on SAD were significant. Conclusions: Consistent with the assumptions of the emotion-focused approach to SAD, these results confirm that early life experiences and humiliation with the development of shame schemes play an important role in the etiology of SAD and must be considered for therapy to be effective. The results of this study suggest that the components of the emotion-focused model can have therapeutic value as targets of intervention in randomized clinical trials."

The Scope of Metacognitive Therapy in the Treatment of Psychiatric Disorders

Metacognitive therapy (MCT) is a novel and promising transdiagnostic psychotherapy intervention based on the Self-Regulatory Executive Function model of conceptualizing emotional disorders. It was developed by Adrian Wells in 2009. Its therapeutic response occurs by reducing dysfunctional metacognitive beliefs regarding worry and rumination, often seen in patients with psychiatric disorders. Since its inception, it has been increasingly applied to a wide spectrum of psychiatric illnesses, but mainly focusing on mood and anxiety disorders. To our knowledge, no study has detailed its existing therapeutic scope in psychiatry. In this comprehensive narrative review, we describe the various psychiatric illnesses in which MCT has been used, the advantages of MCT, and the limitations of the MCT research. In addition, we propose some solutions to systematically examine its place in psychiatry. We encountered its potential role in treating trauma and stress-related disorders, obsessive-compulsive spectrum disorders, personality disorders, psychotic disorders, substance use disorders, and sexual disorders.

The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach

Background

Previous theoretical models and reviews have documented a strong connection between emotion dysregulation eating disorder (ED) psychopathology among the general and clinical populations. The aim of this review was to build on this previous work by conducting a network meta-analysis to explore associations between adaptive and maladaptive emotion regulation strategies and ED psychopathology trans-diagnostically across the ED spectrum to identify areas of emotion dysregulation that have the strongest association with symptomatology.

Methodology

A total of 104 studies were included in the meta-analysis and correlation coefficient representing the associations between specific emotion regulation strategies and ED symptomatology were extracted. We ran a Bayesian random effects network meta-analysis and the initial network was well-connected with each emotion regulation strategy being linked to at least one other strategy. We also conducted a network meta-regression to explore whether between-study differences in body mass index (BMI), age, and whether the sample consisted of solely female participants explained any possible network inconsistency.

Results

The network meta-analysis revealed that ruminations and non-acceptance of emotions were most closely associated with ED psychopathology. There was no significant network inconsistency but two comparisons approached significance and thus meta-regressions were conducted. The meta-regressions revealed a significant effect of BMI such that the associations between different emotion regulation strategies and ED symptomatology were weaker among those with low BMI.

Discussion

The present findings build on previous work and highlight the role of rumination and difficulties with accepting emotions as key emotion regulation difficulties in EDs. Additionally, the finding that the associations were weaker among ED patients with low BMI may point toward a complex relationship between ED behaviors and emotion regulation. Taken together, our findings call for interventions that target emotion regulation, specifically rumination and difficulties accepting emotions, in the treatment of EDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249996, PROSPERO, identifier: CRD42021249996.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011-2019 and a manual search for the years 2019-2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Metacognitive Beliefs and Suicidal Ideation: An Experience Sampling Study

The current study aimed to examine the relationship between metacognitive beliefs about suicidal ideation and the content and process of suicidal ideation. This was to examine the potential contribution of the Self-Regulatory Executive Function (S-REF) model (Wells and Matthew, 2015) to suicidal ideation. Twenty-seven participants completed both trait and state-level measures of suicidal ideation, negative affect, defeat, hopelessness, entrapment and metacognitive beliefs. Experience Sampling Methodology (ESM) was adopted to measure state-level measurements with participants invited to complete an online diary up to seven times a day for six days. Multi-level modelling enabled a detailed examination of the relationships between metacognitive beliefs and suicidal ideation. Positive (β = 0.241, p < 0.001) and negative (β = 0.167, p < 0.001) metacognitive beliefs about suicidal ideation were positively associated with concurrent suicidal ideation even when known cognitive correlates of suicide were controlled for. The results have important clinical implications for the assessment, formulation and treatment of suicidal ideation. Novel meta-cognitive treatments targeting beliefs about suicidal ideation are now indicated. A limited range of characteristics reported by participants affects the generalizability of findings. Future research is recommended to advance understanding of metacognition and suicide but results demonstrate an important contribution of the S-REF model.

The Combined Contribution of Fear and Perceived Danger of COVID-19 and Metacognitions to Anxiety Levels during the COVID-19 Pandemic

Despite a wide base of research suggesting a major role for dysfunctional metacognitions in contributing to anxiety, their role in explaining psychological distress in the context of the COVID-19 pandemic remains unclear. In this study we investigated whether metacognitions would predict anxiety, while controlling for fear and perceived danger of COVID-19. A total of 862 individuals were included in this study. Participants completed sociodemographic questions, emotional state questions relating to COVID-19, the Metacognitions Questionnaire-30, and the Generalized Anxiety Disorder-7. Results showed that both negative beliefs about thoughts concerning uncontrollability and danger, and cognitive self-consciousness were significant predictors of anxiety beyond the fear and perceived danger of COVID-19. Future studies involving clinical populations are needed to investigate the longer-term impact of metacognitions in the maintenance and exacerbation of anxiety associated with the fear and perceived danger of COVID-19.

How Local and Global Metacognition Shape Mental Health

Metacognition is the ability to reflect on our own cognition and mental states. It is a critical aspect of human subjective experience and operates across many hierarchical levels of abstraction-encompassing local confidence in isolated decisions and global self-beliefs about our abilities and skills. Alterations in metacognition are considered foundational to neurologic and psychiatric disorders, but research has mostly focused on local metacognitive computations, missing out on the role of global aspects of metacognition. Here, we first review current behavioral and neural metrics of local metacognition that lay the foundation for this research. We then address the neurocognitive underpinnings of global metacognition uncovered by recent studies. Finally, we outline a theoretical framework in which higher hierarchical levels of metacognition may help identify the role of maladaptive metacognitive evaluation in mental health conditions, particularly when combined with transdiagnostic methods.

Validity and Reliability of the Turkish Version of Generalized Anxiety Disorder Scale-Revised

OBJECTIVE

This study aims to assess the psychometric values of the Generalized Anxiety Disorder Scale-Revised (GADS-R) which measures the intensity and duration of worry, various coping and avoidance strategies to cope with worrying, and positive and negative metacognitive beliefs about worrying.

METHODS

114 patients with generalized anxiety disorder and 198 healthy controls were included in the study. These patients were diagnosed according to DSM-IV TR, and the primary diagnosis of the patients was generalized anxiety disorder which was confirmed via SCID I and II, subsequently. Sociodemographic form, GADS-R total and subscale scores, and Meta-Cognitions Questionnaire-30 (MCQ-30), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder-7 Scale (GAD-7), and Penn State Worry Questionnaire (PSWQ) were used to assess validity, reliability and cut-off point.

RESULTS

GADS-R total and subscale scores and MCQ-30, BDI, BAI, GAD-7, and PSWQ were found to be statistically higher in the patients with GAD compared to a healthy control group. GADS-R has five factors and showed relatively acceptable sensitivity and specificity for detecting anxiety disorders at a cut-off point of 1188.

CONCLUSION

The GADS-R is a valid and reliable scale that can be used in the Turkish population as an assessment tool.

Testing the impaired disengagement hypothesis: The role of attentional control and positive metacognitive beliefs in depression

The impaired disengagement hypothesis holds that people ruminate - and thus increase their risk for depression - due to impaired attentional control and conflict signaling. We tested this hypothesis by examining the role of attentional control and conflict signaling (operationalized as positive metacognitive beliefs) in rumination and depressive symptoms. We expected that attentional control and positive metacognitive beliefs would be associated with depressive symptoms and that these associations would be cross-sectionally mediated by rumination. We tested two community samples (Study 1, N = 289; Study 2, N = 292), assessing attentional control, positive metacognitive beliefs, rumination, and depressive symptoms. In both studies, attentional control and positive metacognitive beliefs were significantly associated with rumination and depression, and path analyses corroborated the proposed mediation model. Our findings support the impaired disengagement hypothesis, and suggest that attentional control and positive metacognitive beliefs may be informative in the personalization of depression assessment and treatment.

Metacognition, rumination and suicidal ideation: An experience sampling test of the self-regulatory executive function model

A relationship between rumination and suicidal ideation is well-evidenced. A role for thought suppression has also been suggested but under-explored. The present study assessed the relative contribution of rumination and a range of thought control strategies in the understanding of suicidal ideation, within the theoretical framework of the self-regulatory executive function (S-REF) model (Wells & Matthews, 2015). Twenty-four participants who had experienced suicidal ideation in the last two months completed trait-level measures of metacognitive beliefs and momentary sampling measures of thought control strategy use, rumination and suicidal ideation over six days. Maladaptive thought control strategy use (worry and punishment), alongside rumination, predicted suicidal ideation. Adaptive strategies (distraction, social control and reappraisal) emerged as negative predictors. Metacognitive beliefs about the need to control thoughts predicted the use of punishment- but not worry-based thought control strategies. Thought control strategy use is as important in the development of suicidal ideation as rumination. The S-REF model represents a promising new approach to understanding these processes in the development of suicidal ideation.

Change in Interpersonal and Metacognitive Skills During Treatment With Cognitive Behavioral Analysis System of Psychotherapy and Metacognitive Therapy: Results From an Observational Study

Background: Interpersonal skills deficits and dysfunctional metacognitive beliefs have been implicated in the etiology and maintenance of depression. This study aimed to investigate the association between changes in these skills deficits and change in depressive symptoms over the course of treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT). Methods: In this prospective, parallel group observational study, data was collected at baseline and after 8 weeks of an intensive day clinic psychotherapy program. Based on a shared decision between patients and clinicians, patients received either CBASP or MCT. Ninety patients were included in the analyses (CBASP: age M = 38.7, 40.5% female, MCT: age M = 44.7, 43.3% female). Interpersonal deficits were assessed with the short-form of the Luebeck Questionnaire for Recording Preoperational Thinking (LQPT-SF) and the Impact Message Inventory (IMI-R). Metacognitive beliefs were assessed with the Metacognition Questionnaire-30 (MCQ-30). The Quick Inventory of Depressive Symptomatology (QIDS-SR16) was utilized to assess depressive symptoms. A regression analysis was conducted to assess variables associated with outcome. ANCOVAs were utilized to investigate whether improvement in skills deficits is dependent on type of treatment received. Results: Improvements in preoperational thinking and increases in friendly-dominant behavior were associated with change in depressive symptoms. There was no association between reductions in dysfunctional metacognitive beliefs and a decrease in depressive symptoms. While both treatment groups showed significant improvements in interpersonal and metacognitive skills, there was no significant between-group difference in the change scores for either of these skills. Conclusion: Our findings suggest that changes in interpersonal skills seem to be of particular relevance in the treatment of depression. These results have to be replicated in a randomized-controlled design before firm conclusions can be drawn.

Loneliness during the COVID-19 pandemic: change and predictors of change from strict to discontinued social distancing protocols

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic and the social distancing protocols designed to impede transmission of the corona virus have severe mental health consequences. This study examine changes in loneliness in the general adult population when the corona-related social distancing protocols were largely discontinued (T2) following a period of strict protocols (T1), predictors and correlates of these changes, and the associations between loneliness and depression and anxiety symptoms.

DESIGN

In an online survey, 10,061 responded at T1. At T2, these respondents were asked to complete the survey again, and 4936 (49.1%) of them responded.

RESULTS

Loneliness decreased from T1 to T2, but only to a minor extent. Using a multilevel approach, younger age was found to be related to more reduction of loneliness from T1 to T2. Higher health anxiety was found to predict less reduction of loneliness across time. Reduction of maladaptive coping strategies and negative metacognitive beliefs from T1 to T2 were both associated with reduction in loneliness. In turn, reductions in loneliness were associated with reductions of depression and anxiety symptoms.

CONCLUSIONS

The results suggest that health anxiety, maladaptive coping strategies and negative meta-beliefs are potential targets of intervention to alleviate loneliness.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04444115.

Therapist-guided online metacognitive intervention for excessive worry: a randomized controlled trial with mediation analysis

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156.

A Mobile-Based Intervention to Increase Self-esteem in Students With Depressive Symptoms: Randomized Controlled Trial

Background

Depressive symptoms are one of the most common and ever-increasing mental health problems among students worldwide. Conventional treatment options, particularly psychotherapy, do not reach all students in need of help. Internet- and mobile-based interventions are promising alternatives for narrowing the treatment gap.

Objective

In the framework of a randomized controlled trial, we aim to investigate the effectiveness, acceptance, and side effects of a self-help smartphone app (MCT & More) based on cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and metacognitive training in a sample of students with self-reported depressive symptoms. Furthermore, we were interested in examining the influence of treatment expectations and attitudes toward internet- and mobile-based interventions on treatment adherence and effectiveness.

Methods

A total of 400 students were recruited via open access websites and randomized to either the intervention group (n=200), who received access to the self-help smartphone app MCT & More for a period of 4 weeks, or to a wait-list control group (n=200). The Patient Health Questionnaire-9 (depression) served as the primary outcome parameter, and the Rosenberg Self-esteem Scale (self-esteem) and the global item of the World Health Organization Quality of Life-abbreviated version (quality of life) served as the secondary outcome parameters. The Attitudes Towards Psychological Online Interventions was used to measure attitudes toward internet- and mobile-based interventions. Outcome expectations were assessed using the Patient Questionnaire on Therapy Expectation and Evaluation, and side effects were assessed using the Inventory for Assessing Negative Effects of Psychotherapy.

Results

Per-protocol (PP), complete-case, and intention-to-treat analyses showed a significantly higher reduction in depressive symptoms (PP: F_1,222=3.98; P=.047; d=0.26) and a significantly higher increase in self-esteem (PP: F_1,220=8.79; P=.003; d=0.40) in the intervention group than in the wait-list control group. Most participants regularly used the self-help smartphone app (91/120, 75.8%, at least once a week). The more positive the attitude toward internet- and mobile-based interventions (r=0.260; P=.004) and the more positive the outcome expectation (r=0.236; P=.009), the more frequently the self-help smartphone app was used.

Conclusions

The effectiveness of the self-help smartphone app MCT & More was demonstrated among students with depressive symptoms compared with a wait-list control group. The app could be offered regularly as a low-threshold intervention to enhance students’ health.

Trial Registration

German Clinical Trials Register DRKS00020941; https://tinyurl.com/pr84w6er

Work-focused therapy for common mental disorders: A naturalistic study comparing an intervention group with a waitlist control group

BACKGROUND:

Common mental disorders (CMD) are leading causes of sickness absence. Treatments for CMD that both reduce symptoms and support work participation urgently need to be developed.

OBJECTIVE:

Determine the potential effects of work-focused therapy combining work interventions with either meta cognitive therapy or cognitive behavioural therapy (W-MCT/CBT) for patients with CMD on sick leave.

METHODS:

Naturalistic study with a quasi-experimental approach. Pre- and post-scores (return to work, symptoms, return-to-work self-efficacy, clinical recovery from depression and anxiety) were compared between the intervention group (n = 87) who received immediate treatment over an average of 10.40 sessions (SD = 3.09) and the non-randomized waitlist control group (n = 95) that had waited an average of 11.18 weeks (SD = 2.29).

RESULTS:

Significantly more patients returned fully to work in the intervention group (41.4%) than the control group (26.3%). Effect sizes for self-efficacy scores, depression and anxiety were large in the intervention group (d = 1.28, 1.01, 1.58), and significantly lower in the control group (d = 0.60, 0.14, 0.45). Significantly more patients in the treatment group than control group recovered from depression (54.1% vs. 12.8%) and anxiety (50.0% vs.10.6%).

CONCLUSIONS:

W-MCT/CBT may be an effective intervention for patients on sick leave due to CMD.

The effect of the emotion regulation training on the resilience of caregivers of patients with schizophrenia: a parallel randomized controlled trial

Background

Schizophrenia is the most severe mental chronic disabling disease that the majority of the patients need constant care in a variety of aspects. Regarding the role of family caregivers in taking care of these patients, caregivers need to be resilient, in addition to other psychological traits, to adapt to the circumstance. This study aimed to investigate the effect of the emotion regulation training on the resilience of caregivers of patients with schizophrenia in southeastern Iran.

Methods

The study was a parallel randomized controlled trial. Seventy caregivers of patients with schizophrenia were selected by convenience sampling method and randomly assigned to an emotion regulation training group and a control group. The intervention group received eight 90-min training sessions (one session weekly) about emotion regulation. The participants completed the Conner–Davidson resilience scale before and one month after the intervention.

Results

The mean scores of the resilience increased in the control and intervention groups at the end of the study. A significant difference was found between the two groups (p < 0.001). At the beginning of the study, the mean score of the resilience was 59.94 in the control group and 51.97 in the intervention group. However, the mean score of the resilience in the control group was 61.28 after the intervention, which was not significant, but it was 69.08 in the intervention group, which was significant. A significant difference was observed between two groups in the mean scores (p = 0.01).

Conclusions

According to the results of this study, cognitive and metacognitive skills of emotion regulation can be suggested as one of the methods for increasing the psychological well-being of schizophrenia patients’ caregivers. The increase of mental well-being and resilience of caregivers can help them better manage a patient with schizophrenia.

Trial registration IRCT registration number: IRCT2017061733997N2, Registration date: 2017-08-16, 1396/05/25, Registration timing: prospective, https://en.irct.ir/trial/26116

Efficacy of third wave cognitive behavioral therapies in the treatment of posttraumatic stress: A meta-analytic study

The purpose of the present study was to examine, via meta-analysis, the efficacy of third wave therapies in reducing posttraumatic stress (PTS) symptoms. A secondary aim was to identify whether treatment efficacy was moderated by treatment type, treatment duration, use of exposure, use of intent-to-treat samples, and treatment format (i.e., individual, group, both). Risk of bias was also assessed. A literature search returned 37 studies with a pooled sample of 1268 participants that met study inclusion criteria. The mean differences between pre- and post-treatment PTS symptoms were estimated using a random effects model (i.e., uncontrolled effect). Additionally, in a subset of studies that utilized a control condition, a controlled effect in which pre- to post-treatment PTS symptom changes accounted for symptom changes in the control condition was calculated. The overall uncontrolled effect of third wave therapies in reducing PTS symptoms was medium to large (Hedges' g = 0.88 [0.72-1.03]). Treatment type, use of intent-to-treat analysis, inclusion of exposure, and format moderated the uncontrolled effect, but treatment duration did not. The controlled effect of third wave therapies was small to large in size (Hedges' g = 0.50 [0.20-0.80]). Findings suggest that third wave therapies demonstrate enough promise in treating individuals with PTS symptoms to warrant further investigation. Implications and suggestions for future third wave research are discussed.

Effects of the Attention Training Technique on Brain Activity in Healthy University Students Assessed by EEG Source Imaging

This study aimed to investigate the neurocognitive effects of the Attention Training Technique (ATT) on brain activity in healthy participants. The participants included 20 university students who were asked to practice ATT as a homework assignment for 20 days. The intracerebral source localization of their electroencephalogram during rest and the ATT task, which comprised selective attention, attention switching, and divided attention conditions, was evaluated by standardized low-resolution brain electromagnetic tomography. Brain activity during rest was subtracted from that during the ATT task, and that was compared before and after the homework assignment. The results for the divided attention condition indicated significantly decreased alpha 1 frequency band power in the left orbital frontal cortex (OFC) and alpha 2 power in the right inferior temporal cortex. Further, decreased alpha 1 power in the left OFC correlated with reduced subjective difficulty during the divided attention condition. One possibility is that the brain activity changed as the effect of ATT practice, although this study cannot confirm causality. Further studies are required which include a control group that would complete similar training without the ATT task.

Metacognitive Therapy for Work-Related Stress: A Feasibility Study

About 25% of EU workers experience work-related stress for all or most of their working time, showing that work-related stress is a major cause of health problems for the EU population. This situation has been worsened even more by the COVID-19 restrictions embraced by employers worldwide. However, a timely and sustainable intervention protocol for treating such issues has not been developed yet. Thus, the present research shows a first effective attempt based on Metacognitive therapy (MCT) to solve this issue. MCT was practiced on four individuals suffering from chronic work-related stress. Primary outcome variables were general mental health, perceived stress, and blood pressure. Participants were assessed at multiple baselines before the start of therapy and then attended a 3- and 6-months follow-up after treatment termination. Results showed significant improvements in general mental health, perceived stress, and blood pressure in each client. Secondary outcome variables improved too-maladaptive coping strategies, avoidance behaviors, and depression symptoms-corroborating the main findings. At 3- and 6-month follow-up, results were maintained. The findings suggest that MCT might be a promising and sustainable intervention for work-related stress, although a metacognitive model for stress and large-scale RCTs need to be developed and carried out to further explore the effect of MCT on stress. Our results represent one of the first attempts to treat work-related stress via Metacognitive Therapy and support the feasibility of the treatment, both in terms of its efficacy and sustainability, in a historical moment in which work-related stress is increased worldwide because of the COVID-19 pandemic. Within such a realm, our feasibility study should be followed by larger and controlled studies that, if successful, would provide various stakeholders-including organizational and institutional decision-makers-with a solid, timely and cost-effective method to help the workforce coping with work-related stress.

Loneliness and Social Distancing During the COVID-19 Pandemic: Risk Factors and Associations With Psychopathology

Background: The mitigation strategies employed against the COVID-19 pandemic have severe mental health consequences. In particular, as a result of the social distancing protocols, loneliness is likely to increase. This study investigates (a) potential risk and resilience factors for loneliness in the Norwegian population during the strict social distancing non-pharmacological interventions (NPIs) implemented against the pandemic and (b) the associations between loneliness and psychopathology symptoms. Methods: A survey was disseminated online to the adult Norwegian population when strict social distancing measures had been implemented for 2 weeks. The resulting sample of 10,061 respondents was unproportionate in terms of gender and educational level and thus sensitivity analyses were conducted. The levels of loneliness were compared across demographic sub-groups, and regression analyses were conducted to identify potential risk and resilience factors for loneliness and associations between loneliness and psychopathology symptoms. Results: Among the stable factors, being single and having a psychiatric diagnosis were related to more loneliness with small effect sizes. Among the state risk factors, more rumination and worry in general were associated with stronger loneliness, showing a medium effect size. Among the coping behaviors examined, doing new things at home not done otherwise was negatively related to loneliness, with a small effect size. Loneliness was associated with both depression and anxiety with small effect sizes when all potential confounders and psychiatric diagnosis were controlled for. The relationship to depression was more marked than the relationship to anxiety. Conclusions: The findings suggest that singles and those with a psychiatric diagnosis were most affected by loneliness during the implementation of social distancing measures to impede the coronavirus. The results support the link between loneliness and depression and anxiety symptoms. The results of the analysis of potential risk and resilience factors point to intervention targets for reducing loneliness during pandemic crises.

The Effect of State and Trait Self-Critical Rumination on Acute Distress: An Exploratory Experimental Investigation

Self-critical rumination is a process whereby individuals focus attention on past failures and inadequacies without consideration for improvement or problem-solving. Past research has demonstrated that self-critical rumination is a separate process from the experience of having intrusive self-critical thoughts and that engaging in self-critical rumination is strongly correlated with beliefs that it is uncontrollable or represents a weakness of character. What is less clear at this time, however, is the impact that self-critical rumination has on levels of distress when faced with failure. Thirty volunteers who were not experiencing significant levels of depression were randomly assigned across three groups: one rumination and two controls. Acute distress was measured prior to and immediately following a task, as well as upon debrief. Individuals expected to complete an impossible task, who experienced simulated self-critical rumination experienced greater levels of acute distress than controls immediately following the task. There was also a significant correlation between reported levels of trait self-critical rumination, negative metacognitive beliefs and self-esteem with levels of distress following debrief when controlling for initial levels of distress and group membership. The use of subjective self-reports and small sample size limits the findings of this exploratory study. Engaging in self-critical rumination, and associated negative metacognitive beliefs, may have a significant impact on levels of acute distress following a recent failure.

Temporal and Reciprocal Relations Between Worry and Rumination Among Subgroups of Metacognitive Beliefs

Metacognitive theory provides strong foundation for hypothesizing relations between worry and rumination among subgroups of metacognitive beliefs. However, empirical exploration of prospective and reciprocal relations between worry and rumination are lacking. This study investigated the stability and relations between worry and rumination to better understand how they influence each other over time, and how different levels of metacognitive beliefs affect relations between (i) initial and future worry, and initial and future rumination, and (ii) the cross-lag relations between worry and rumination. Overall, 482 (Females = 63%) participants (Mean age = 26 years) participated in a two-wave data collection and completed the Metacognition Questionnaire (MCQ-30), the Ruminative Response Scale and the Penn State Worry Questionnaire (PSWQ). A multigroup two-wave autoregressive cross-lagged model was estimated. Multigroup autoregression analyses revealed that independent of participants being in the high or low metacognition group, initial levels of worry predicted future levels of worry, as was the case for rumination. Multigroup cross-lagged analyses revealed that initial levels of worry did not predict future levels of rumination in both high and low levels of metacognitions. However, initial rumination predicted future levels of worry in the high metacognitions group, which was not the case for the low metacognitions group. Thus, high levels of metacognitions do not only strengthen the relation between both present and future worry, present and future rumination, but also present rumination with future worry. This finding may imply that those with rumination related conditions at present are more likely in the future to show both rumination and worry related conditions. Conversely, those with worry related conditions show future worry related conditions. These findings may have implications for a clinical sample regarding the high complexity of rumination conditions that may proceed with multifinality causal pathways especially for individuals with high levels of metacognitions. This complexity may be a possible explanation for the limited success in other traditional treatment of rumination related conditions and the relatively high relapse rates for such conditions in clinical samples.

Protocol for the economic evaluation of metacognitive therapy for cardiac rehabilitation participants with symptoms of anxiety and/or depression

INTRODUCTION

Cardiac rehabilitation (CR) is offered to reduce the risk of further cardiac events and to improve patients' health and quality of life following a cardiac event. Psychological care is a common component of CR as symptoms of depression and/or anxiety are more prevalent in this population, however evidence for the cost-effectiveness of current interventions is limited. Metacognitive therapy (MCT), is a recent treatment development that is effective in treating anxiety and depression in mental health settings and is being evaluated in CR patients. This protocol describes the planned approach to the economic evaluation of MCT for CR patients.

METHODS AND ANALYSIS

The economic evaluation work will consist of a within-trial analysis and an economic model. The PATHWAY Group MCT study has been prospectively designed to collect comprehensive self-reported resource use and health outcome data, including the EQ-5D, within a randomised controlled trial study design (UK Clinical Trials Gateway). A within-trial economic evaluation and economic model will compare the cost-effectiveness of MCT plus usual care (UC) to UC, from a health and social care perspective in the UK. The within-trial analysis will use intention-to-treat and estimate total costs and quality-adjusted life-years (QALYs) for the trial follow-up. Single imputation will be used to impute missing baseline variables. Multiple imputation will be used to impute values missing at follow-up. Items of resource use will be multiplied by published national healthcare costs. Regression analysis will be used to estimate net costs and net QALYs and these estimates will be bootstrapped to generate 10 000 net pairs of costs and QALYs to inform the probability of cost-effectiveness. A decision analytical economic model will be developed to synthesise trial data with the published literature over a longer time frame. Sensitivity analysis will explore uncertainty. Guidance of the methods for economic models will be followed and dissemination will adhere to reporting guidelines.

ETHICS AND DISSEMINATION

The economic evaluation includes a within-trial analysis. The trial which included the collection of this data was reviewed and approved by Ethics. Ethics approval was obtained by the Preston Research Ethics Committee (project ID 156862). The modelling analysis is not applicable for Ethics as it will use data from the trial (secondary analysis) and the published literature. Results of the main trial and economic evaluation will be published in the peer-reviewed National Institute for Health Research (NIHR) journals library (Programme Grants for Applied Research), submitted to a peer-reviewed journal and presented at appropriate conferences.

TRIAL REGISTRATION NUMBER

ISRCTN74643496; Pre-results.

Effects of attention training technique on brain function in high- and low-cognitive-attentional syndrome individuals: Regional dynamics before, during, and after a single session of ATT

OBJECTIVE

Attention Training Technique (ATT) is a key therapeutic tool in metacognitive therapy. There are numerous studies on the behavioral effects of ATT, however the neural mechanisms at work in the training are yet to be uncovered. To date there have been no controlled fMRI studies of ATT.

METHOD

We conducted a randomized double-blind controlled study of two groups with varying levels of cognitive-attentional syndrome (CAS). Groups with high (n = 43) and low (n = 46) levels of CAS underwent a single session of ATT or a control condition (CON) in an MRI scanner. Participants underwent resting state functional MRI (rsfMRI) sessions and rumination induction sessions both pre- and post-intervention Functional connectivity analyses and inter-subject correlations analyses were computed. We also collected data on emotion and attention functioning pre- and post-intervention.

RESULTS

We did not observe any behavioral effects of ATT. However, direct comparison between ATT and CON sessions revealed greater inter-subject correlations in almost all hubs belonging to the studied functional networks. Moreover, subjects who received ATT showed diminished connectivity in the fronto-parietal network during ruminations and diminished connectivity of the precuneus with lateral occipital cortices and the intraparietal sulcus in abstract thinking and rsfMRI, respectively. Furthermore, some of the observed effects in functional connectivity and inter-subject correlations were specific to different levels of CAS.

CONCLUSIONS

Our results may support a proposed neural mechanism for ATT: disengagement of attention from CAS-type processing in either low- or high-CAS individuals. It is also possible that some neural effects of ATT are specific to individuals with different levels of CAS.

The Effect of Emotion Regulation Training on Stress, Anxiety, and Depression in Family Caregivers of Patients with Schizophrenia: A Randomized Controlled Trial

Schizophrenia is the most severe chronic disabling psychiatric disorder that needs long term care in various aspects. Therefore, the family's emotional atmosphere caused by the disease affects the condition of the patients' caregivers. This study aimed to investigate the effect of emotional regulation training on stress, anxiety, and depression in caregivers of patients with schizophrenia. The study was a randomized controlled trial. Seventy caregivers of patients with schizophrenia randomly assigned to a group that received emotion regulation training and a control group. The intervention group was trained about emotion regulation during eight 90-min sessions. The participants completed the Depression, Anxiety and Stress Scales-21 questionnaire before and one month after the intervention. The results showed that stress, anxiety and depression scores significantly reduced in the intervention group compared to the control group. Emotional regulation training with cognitive methods has significantly reduced the anxiety, stress, and depression of caregivers of patients with schizophrenia.