The Lancet Psychiatry Commission on psychological treatments research in tomorrow's science

Feasibility and efficacy of a digital CBT intervention for symptoms of Generalized Anxiety Disorder: A randomized multiple-baseline study

BACKGROUND AND OBJECTIVES

Cognitive behavioral therapy (CBT) is a first-line treatment for anxiety, but it is not widely available as clinical guidelines recommend. We examined the feasibility and efficacy of a novel smartphone-based fully automated digital CBT intervention, 'Daylight™', to improve symptoms of Generalized Anxiety Disorder (GAD).

METHODS

In this multiple-baseline design, 21 adults (20 F; mean age 43yrs. range 19-65yrs.) with moderate-to-severe symptoms of GAD were randomized to one of three baseline durations (2-, 4-, or 6-weeks) and then received access to digital CBT. Participants completed daily ratings of anxiety and worry, weekly measures of anxiety, depressive symptoms, and sleep, and measures of anxiety, worry, wellbeing, quality of life, CBT skill acquisition, and work performance at initial assessment prior to baseline randomization, post-intervention, and follow-up.

RESULTS

Digital CBT was found to be feasible in terms of engagement, satisfaction, and safety. For preliminary efficacy, improvements were detected in daily and weekly outcomes of anxiety for most participants. Despite individual differences, significant improvements occurred with the introduction of digital CBT and not during baseline. Overall, 70% of participants no longer had clinically significant symptoms of GAD, 61% no longer had significant depressive symptoms, and 40% no longer had significant sleep difficulty at post-intervention.

LIMITATIONS

The study sample was recruited using the internet and was mostly female, limiting the generalizability of the findings.

CONCLUSIONS

Findings support the feasibility and efficacy of Daylight. Further examination in randomized controlled trials is now warranted.

The Effects of Modifying Dysfunctional Appraisals in Posttraumatic Stress Disorder Using a Form of Cognitive Bias Modification: Results of a Randomized Controlled Trial in an Inpatient Setting

INTRODUCTION

Dysfunctional appraisals about traumatic events and their sequelae are a key mechanism in posttraumatic stress disorder (PTSD). Experimental studies have shown that a computerized cognitive training, cognitive bias modification for appraisals (CBM-APP), can modify dysfunctional appraisals and reduce analogue trauma symptoms amongst healthy and subclinical volunteers.

OBJECTIVE

We aimed to test whether CBM-APP could reduce dysfunctional appraisals related to trauma reactions in PTSD patients, and whether this would lead to improvements in PTSD symptoms.

METHODS

We compared CBM-APP to sham training in a parallel-arm proof-of-principle double-blind randomized controlled trial amongst 80 PTSD patients admitted to an inpatient clinic. Both arms comprised a training schedule of 8 sessions over a 2-week period and were completed as an adjunct to the standard treatment programme.

RESULTS

In intention-to-treat analyses, participants receiving CBM-APP showed a greater reduction in dysfunctional appraisals on a scenario task from pre- to posttraining (primary outcome) assessments, compared to those receiving sham training (d = 1.30, 95% CI 0.82-1.80), with between-group differences also found on the Posttraumatic Cognitions Inventory (PTCI; d = 0.85, 95% CI 0.39-1.32) and the PTSD Checklist for DSM-5 (PCL-5; d = 0.68, 95% CI 0.23-1.14), but not for long-term cortisol concentrations (d = 0.25, 95% CI -0.28 to 0.78). Reductions in dysfunctional appraisals assessed via the scenario task correlated with reductions on the PTCI, PCL-5, and hair cortisol concentrations from pre- to posttraining time points.

CONCLUSIONS

Results support dysfunctional appraisals as a modifiable cognitive mechanism, and that their proximal modification transfers to downstream PTSD symptoms. These findings could open new avenues for improving present therapeutic approaches.

Evolution of Clinical Outcome During Adolescents’ Psychiatric Inpatient Care: A Prospective Multiple Informant Study

Background:

Examining the effectiveness and adequacy of adolescents’ psychiatric inpatient treatment through multiple perspectives is crucial to provide the best care.

Objectives:

The aims of the current study were to examine the consistencies and discrepancies between patients and clinicians and to understand how each group considered the timing of improvement of symptoms and psychosocial difficulties of adolescents during a psychiatric inpatient stay.

Methods:

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA, assessing symptoms and psychosocial difficulties) was rated on a weekly basis by patients and clinicians during a psychiatric inpatient stay. Data were collected from 297 patients, 58.2% females.

Results:

Both clinicians and patients reported a significant decrease of the HoNOSCA scores from admission to discharge, revealing that inpatient treatment is perceived as helping the adolescents to alleviate their symptoms and psychosocial difficulties. However, the item-by-item analyses indicated that patients and clinicians reported difficulties in different symptoms and psychosocial domains. Moreover, the week-by-week analyses revealed discrepancies in the perception of the time-course of clinical outcome- changes between clinicians and patients, as well as between males and females, and between voluntarily and involuntarily admitted patients.

Conclusions:

By integrating perspectives of patients and clinicians and their respective timelines, as well as by taking into account the mode of admission and the patient’s gender, this study provides a deeper understanding of the evolution of clinical outcome during adolescents’ hospitalizations, which allows to adapt their treatment and therewith, to help patients more efficiently.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma: Qualitative Interview Study

BACKGROUND

The COVID-19 pandemic has escalated the global need for remotely delivered and scalable interventions after psychological trauma. A brief intervention involving a computer game as an imagery-competing task has shown promising results for reducing the number of intrusive memories of trauma-one of the core clinical symptoms of posttraumatic stress disorder. To date, the intervention has only been delivered face-to-face. To be tested and implemented on a wider scale, digital adaptation for remote delivery is crucial. An important first step is to develop digitalized intervention materials in a systematic way based on feedback from clinicians, researchers, and students in preparation for pilot testing with target users.

OBJECTIVE

The first aim of this study is to obtain and analyze qualitative feedback on digital intervention materials, namely two animated videos and two quizzes that explain the target clinical symptoms and provide intervention instructions. The second aim is to refine the digitalized materials based on this feedback.

METHODS

We conducted semistructured interviews with 12 participants who had delivered or had knowledge of the intervention when delivered face-to-face. We obtained in-depth feedback on the perceived feasibility of using the digitalized materials and suggestions for improvements. Interviews were assessed using qualitative content analysis, and suggested improvements were evaluated for implementation using a systematic method of prioritization.

RESULTS

A total of three overarching themes were identified from the data. First, participants were highly positive about the potential benefits of using these digital materials for remote delivery, reporting that the videos effectively conveyed key concepts of the symptom and its treatment. Second, some modifications to the materials were suggested for improving clarity. On the basis of this feedback, we made nine specific changes. Finally, participants raised some key challenges for remote delivery, mainly in overcoming the lack of real-time communication during the intervention.

CONCLUSIONS

Clinicians, researchers, and clinical psychology students were overall confident in the use of digitalized materials to remotely deliver a brief intervention to reduce intrusive memories of trauma. Guided by participant feedback, we identified and implemented changes to refine the intervention materials. This study lays the groundwork for the next step: pilot testing remote delivery of the full intervention to trauma survivors.

Cognitive Behavior Therapy at the Crossroads

The early development of cognitive behavior therapy (CBT) can be characterized by the coming together of behavioral and cognitive traditions. However, the past decades have arguably seen more divergences than convergences within the field. The 9th World Congress of Behavioural and Cognitive Therapies was held in Berlin in July 2019 with the congress theme "CBT at the Crossroads." This title reflected in part the coming together of people from all over the world, but also the fact that recent developments raise important questions about the future of CBT, including whether we can in fact treat it as a unified field. In this paper, we briefly trace the history of CBT, then introduce a special issue featuring a series of articles exploring different aspects of the past, present, and future of CBT. Finally, we reflect on the possible routes ahead.

A network meta-analysis of psychological interventions for schizophrenia and psychosis: Impact on symptoms

BACKGROUND

Evidence for the effectiveness of psychological interventions for schizophrenia/psychosis is growing, however there is no consensus on the psychological intervention most likely to reduce symptoms.

METHODS

A network meta-analysis was conducted to identify all randomised controlled trials (RCTs) of psychological interventions for adults with schizophrenia/psychosis. A systematic review of the literature using MEDLINE, PsycINFO, EMBASE and CENTRAL led to an analysis of 90 RCTs with 8440 randomised participants across 24 psychological intervention, and control groups. Psychological interventions were categorised and rated for treatment fidelity and risk of bias. Data for total symptoms were extracted and network meta-analysis, using a frequentist approach, was undertaken using Stata SE v15 to compare the direct and indirect evidence for the effectiveness of each psychological intervention.

FINDINGS

Psychological interventions were more likely to reduce symptoms than control groups, and one intervention, mindfulness-based psychoeducation, was consistently ranked as most likely to reduce total symptoms. Subgroup analyses identified differential effectiveness in different settings and for different subgroups.

INTERPRETATION

Mindfulness-based psychoeducation was consistently ranked as most likely to reduce symptoms; however all studies were based in China. More RCTs in a variety of cultural contexts would help to elucidate whether these findings generalise internationally. A number of psychological interventions could potentially be more effective than interventions recommended by NICE guidelines, such as CBT and family therapy, and additional RCTs and meta-analyses are needed to generate more conclusive evidence in this regard.

Mental Imagery in the Science and Practice of Cognitive Behaviour Therapy: Past, Present, and Future Perspectives

Mental imagery has a long history in the science and practice of cognitive behaviour therapy (CBT), stemming from both behavioural and cognitive traditions. The past decade or so has seen a marked increase in both scientific and clinical interest in mental imagery, from basic questions about the processes underpinning mental imagery and its roles in everyday healthy functioning, to clinical questions about how dysfunctions in mental imagery can cause distress and impairment, and how mental imagery can be used within CBT to effect therapeutic change. This article reflects on the current state of mental imagery in the science and practice of CBT, in the context of past developments and with a view to future challenges and opportunities. An ongoing interplay between the various strands of imagery research and the many clinical innovations in this area is recommended in order to realise the full therapeutic potential of mental imagery in CBT.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

(1)

Knowledge of COVID-19 and preventive behaviors among waiters working in food and drinking establishments in Southwest Ethiopia

BACKGROUND

Waiters working in different food and drinking establishments have a higher risk of contracting COVID-19 and transmitting the infection to others because they interact with many people. Most COVID-19 related studies in Ethiopia mainly focused on the general population, whereas, this study aimed to assess the knowledge of COVID-19 and preventive behaviors among waiters in Southwest Ethiopia.

METHODS

A cross-sectional study was conducted from June 1 to June 15, 2020, among waiters working in food and drinking establishments found in Mizan-Aman, Jemu, and Masha towns in Southwest Ethiopia. A total of 422 waiters were selected using a simple random sampling technique, and the data were collected through face-to-face interviews using a structured questionnaire. The data were entered into Epi-data manager version 4.0.2 and analyzed using SPSS version 22. Multivariable binary logistic regression analysis was carried out to identify predictors of good preventive behaviors at a p-value of less than 0.05.

RESULTS

Four hundred and sixteen respondents participated in this study, with a response rate of 98.6%. A significant proportion of participants know the cause, route of transmission, symptoms, and prevention methods of COVID-19 virus. However, very few (21.2%) had good preventive behaviors. The study showed that good preventive behavior was positively associated with female sex (AOR = 2.33, 95% CI: 1.38-3.94), higher schooling (AOR = 0.39, 95% CI: 0.17-0.88), high-risk perception (AOR = 2.26, 95% CI: 1.51-4.32), and high perceived self-efficacy (AOR = 1.1.75, 95% CI: 1.05-2.90).

CONCLUSIONS

A significant proportion of waiters know common symptoms of COVID 19, route of transmission, and its prevention methods. However, the preventive behavior was very low. Thus, all concerned bodies working on the prevention and control of COVID-19 should give attention to this population group to enhance compliance with recommended preventive behaviors.

Relationships with caregivers and mental health outcomes among adolescents living with HIV: a prospective cohort study in South Africa

BACKGROUND

Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question.

METHODS

The study traced adolescents aged 10-19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents.

RESULTS

Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97-0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98-1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92-0.97, p<.0001) and anxiety (0.91, 95% CI 0.89-0.94, p<.0001) symptoms reported by adolescents.

CONCLUSIONS

Findings highlight open and supportive adolescent-caregiver communication and good caregiver supervision as potential factors for guarding against mental health problems among adolescents living with HIV in South Africa. Several evidence-informed parenting programmes aim to improve adolescent-caregiver communication and caregiver supervision, and their effect on depression and anxiety among adolescents living with HIV should be rigorously tested in sub-Saharan Africa. How to improve communication in other settings, such as schools and clinics, and provide communication support for caregivers, adolescents, and service providers through these existing services should also be considered.

Moving from tradition-based to competence-based psychotherapy

Current education and training in psychological interventions is mostly based on different 'schools' (traditions such as cognitive-behavioural or psychodynamic therapy), and strong identification with these specific traditions continuously hinders a scientifically based development of psychotherapy. This review is selective rather than systematic and comprehensive. In addition to the consideration of other influential publications, we relied on a literature search in Web of Science using the following terms (update: 24 December 2020): (psychotherapy AND meta-analy* AND competence*). After summarising current problems, a pathway for solving these problems is presented. First, we have to recategorise psychological interventions according to the mechanisms and subgoals that are addressed. The interventions can be classified according to the foci: (1) skills acquisition (eg, communication, emotion regulation, mentalisation); (2) working with relationship patterns and using the therapeutic relationship to modify them; and (3) clarification of motives and goals. Afterwards, the training of psychotherapists can switch from focusing on one theoretical framework to learning the different competences for modification according to these new categories. The selection of topics to be addressed should follow best evidence-based mechanisms and processes of mental disorders and interventions. Psychology offers knowledge about these mechanisms that can be understood as a basic science for psychological treatments in general. This requires better connection with basic science, new research efforts that focus on treatment subgoals, theory-overarching optimisation of the selection and personalisation of treatments, and new types of training for psychotherapists that are designed to optimise therapists' competences accordingly, instead of limiting training programmes to one single theoretical framework.

Reducing intrusive memories after trauma via a brief cognitive task intervention in the hospital emergency department: an exploratory pilot randomised controlled trial

Intrusive memories are common after trauma, and can cause significant distress. Interventions to prevent/reduce the occurrence of this core clinical feature of posttraumatic stress disorder are needed; they should be easy to deliver, readily disseminated and scalable. A novel one-session intervention by Iyadurai et al. 2018, Molecular Psychiatry, resulted in intrusion reduction over the subsequent week. Its feasibility in a different setting and longer-term effects (>1 month) need investigation. We conducted an exploratory open-label pilot randomised controlled trial (RCT) to investigate the feasibility and effects of a brief behavioural intervention to reduce intrusive memories in trauma-exposed patients in a Swedish hospital emergency department (ED). Participants (final N = 41) were randomly allocated to either intervention (including memory reminder cue then visuospatial cognitive task "Tetris" with mental rotation instructions) or active control (podcast) condition within 72 h of presenting to the ED (both conditions using their smartphone). Findings were examined descriptively. We estimated between-group effect sizes for the number of intrusive memories post-intervention at week 1 (primary outcome) and week 5 (secondary outcome). Compared to the control condition, participants in the intervention condition reported fewer intrusive memories of trauma, both at week 1 and week 5. Findings extend the previous evaluation in the UK. The intervention was readily implemented in a different international context, with a mixed trauma sample, with treatment gains maintained at 1 month and associated with some functional improvements. Findings inform future trials to evaluate the capacity of the cognitive task intervention to reduce the occurrence of intrusive memories after traumatic events.

Longitudinal Associations of Mental Disorders With Physical Diseases and Mortality Among 2.3 Million New Zealand Citizens

IMPORTANCE

Excess risk of physical disease and mortality has been observed among individuals with psychiatric conditions, suggesting that ameliorating mental disorders might also be associated with ameliorating the later onset of physical disability and early mortality. However, the temporal association between mental disorders and physical diseases remains unclear, as many studies have relied on retrospective recall, used cross-sectional designs or prospective designs with limited follow-up periods, or given inadequate consideration to preexisting physical illnesses.

OBJECTIVE

To examine whether mental disorders are associated with subsequent physical diseases and mortality across 3 decades of observation.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the New Zealand Integrated Data Infrastructure, a collection of nationwide administrative data sources linked at the individual level, to identify mental disorders, physical diseases, and deaths recorded between July 1, 1988, and June 30, 2018, in the population of New Zealand. All individuals born in New Zealand between January 1, 1928, and December 31, 1978, who resided in the country at any time during the 30-year observation period were included in the analysis. Data were analyzed from July 2019 to November 2020.

EXPOSURES

Nationwide administrative records of mental disorder diagnoses made in public hospitals.

MAIN OUTCOMES AND MEASURES

Chronic physical disease diagnoses made in public hospitals, deaths, and health care use.

RESULTS

The study population comprised 2 349 897 individuals (1 191 981 men [50.7%]; age range at baseline, 10-60 years). Individuals with a mental disorder developed subsequent physical diseases at younger ages (hazard ratio [HR], 2.33; 95% CI, 2.30-2.36) and died at younger ages (HR, 3.80; 95% CI, 3.72-3.89) than those without a mental disorder. These associations remained across sex and age and after accounting for preexisting physical diseases. Associations were observed across different types of mental disorders and self-harm behavior (relative risks, 1.78-2.43; P < .001 for all comparisons). Mental disorders were associated with the onset of physical diseases and the accumulation of physical disease diagnoses (incidence rate ratio [IRR], 2.00; 95% CI, 1.98-2.03), a higher number of hospitalizations (IRR, 2.43; 95% CI, 2.39-2.48), longer hospital stays for treatment (IRR, 2.70; 95% CI, 2.62-2.79), and higher associated health care costs (b = 0.115; 95% CI, 0.112-0.118).

CONCLUSIONS AND RELEVANCE

In this study, mental disorders were likely to begin and peak in young adulthood, and they antedated physical diseases and early mortality in the population. These findings suggest that ameliorating mental disorders may have implications for improving the length and quality of life and for reducing the health care costs associated with physical diseases.

Using Imagery Rescripting as an Early Intervention for Depression in Young People

Innovation is urgently needed for school-based early interventions for depression. Imagery rescripting for aversive memories has been shown to be a valuable therapeutic approach in adults. Yet it is rarely applied to young people or to depression. This is surprising given that intrusive images of aversive memories are implicated in the development and maintenance of depression. We review the literature and describe the co-development of an imagery rescripting protocol for young people (age 16-18) with high symptoms of depression. To contextualize and illustrate this approach, we identify three themes of negative images emerging from the 37 participants who completed imagery rescripting and provide a detailed case example for each theme. The identified themes are failure, interpersonal adversity, and family conflict or disruption. Given that there is some therapist concern about using imagery rescripting, we highlight any reported negative consequences of engaging in imagery rescripting. We propose that imagery rescripting is an acceptable and potentially effective tool for early intervention in depression, which is significantly underutilized in current practice.

Delayed gaze shifts away from others' eyes in children and adolescents with social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is linked to atypical attention to other's eyes. Empirical literature about this phenomenon in childhood and adolescence is scarce. Previous studies in adults have suggested that SAD may be characterized by either rapid avoidance of eye contact, or by impaired shifting of attention away from eyes once eye contact has been established. SAD has also been linked to quick orienting towards eyes, indicating vigilant monitoring of perceived threat.

METHODS

In the largest eye-tracking study of youth with SAD to date, 10 to 17 year-olds with SAD (n = 88) and healthy controls (n = 62) were primed to look at either the eyes or the mouth of human faces. The latency and likelihood of a first gaze shift from, or to the eyes, was measured.

RESULTS

Individuals with SAD were slower to shift their gaze away from the eye region of faces than controls, but did not differ in orienting toward eyes.

LIMITATIONS

Participants were assessed once after the onset of SAD symptoms, meaning that the longitudinal predictive value of delayed gaze shifts from others' eyes could not be examined.

CONCLUSIONS

Youth with SAD may be impaired in shifting attention from other's eyes. This could contribute to the experience of eye contact as aversive, and may be a maintaining factor of childhood SAD.

Brain+ AlcoRecover: A Randomized Controlled Pilot-Study and Feasibility Study of Multiple-Domain Cognitive Training Using a Serious Gaming App for Treating Alcohol Use Disorders

Background: Patients with alcohol use disorder (AUD) exhibit deficits in various cognitive domains, including executive functioning, working memory, and learning and memory, which impede the effectiveness of conventional AUD treatment and enhance relapse. Mobile health (mHealth) services are promising in terms of delivering cognitive training in gamified versions. So far, studies examining the effects of mHealth-based cognitive training in AUD patients have, however, focused on specific rather than multiple cognitive domains and overlooked the importance of clinical outcomes. Furthermore, research has yet to investigate the acceptability and feasibility of this type of cognitive training. Aims: The aims of this pilot study are to examine (1) whether using smartphone-based, multi-domain cognitive training with gamified elements as part of conventional treatment for AUD indicate effect, and (2) whether the intervention is acceptable and feasible as a part of conventional treatment for AUD. Methods: Patients from the alcohol outpatient clinic, Odense Municipality, Denmark will be invited to participate in the study on a consecutive basis until a total of 60 patients have been recruited. The study will be performed as a combined parallel randomized controlled trial (RCT) and qualitative feasibility study. The patients will be randomly assigned to one of two groups. The intervention group (n = 30) will receive smartphone-based, multi-domain cognitive training with gamified elements together with treatment as usual (TAU). The active control group (n = 30) will receive a sham version of the same cognitive training together with TAU. Cognitive outcomes will be assessed via the training application at baseline and post-treatment. Clinical outcomes will be assessed at baseline, post-treatment, and at 6-month follow-up using the Addiction Severity Index. Furthermore, the 30 patients randomized to the intervention group will be invited to participate in the second phase, that is the feasibility study, at post-treatment. A questionnaire inquiring about the use of mHealth treatment in general will be administered. Further, feedback regarding functionality and meaningfulness of the application in addition to other qualitative aspects relating to the use of the application will be collected. The patients will also be asked to provide suggestions about how to improve and potentially implement the tool. Implications: It is anticipated that this pilot study will provide tentative evidence for the effectiveness of smartphone-based, multi-domain cognitive training as well as information about the usability and feasibility of this type of training, including acceptability and compliance. The study will also contribute with feedback derived from the patients about how to improve and implement the tool. If promising, the findings will be used to plan a large-scale RCT. Since cognitive deficits are not addressed in current treatments for AUD, gamified cognitive training delivered through smartphones may increase the effectiveness of current treatment for AUD as well as introduce more mHealth-based treatment that is both accessible and cost-effective.

Predicting Symptoms of Depression and Anxiety Using Smartphone and Wearable Data

Background: Depression and anxiety are leading causes of disability worldwide but often remain undetected and untreated. Smartphone and wearable devices may offer a unique source of data to detect moment by moment changes in risk factors associated with mental disorders that overcome many of the limitations of traditional screening methods. Objective: The current study aimed to explore the extent to which data from smartphone and wearable devices could predict symptoms of depression and anxiety. Methods: A total of N = 60 adults (ages 24-68) who owned an Apple iPhone and Oura Ring were recruited online over a 2-week period. At the beginning of the study, participants installed the Delphi data acquisition app on their smartphone. The app continuously monitored participants' location (using GPS) and smartphone usage behavior (total usage time and frequency of use). The Oura Ring provided measures related to activity (step count and metabolic equivalent for task), sleep (total sleep time, sleep onset latency, wake after sleep onset and time in bed) and heart rate variability (HRV). In addition, participants were prompted to report their daily mood (valence and arousal). Participants completed self-reported assessments of depression, anxiety and stress (DASS-21) at baseline, midpoint and the end of the study. Results: Multilevel models demonstrated a significant negative association between the variability of locations visited and symptoms of depression (beta = -0.21, p = 0.037) and significant positive associations between total sleep time and depression (beta = 0.24, p = 0.023), time in bed and depression (beta = 0.26, p = 0.020), wake after sleep onset and anxiety (beta = 0.23, p = 0.035) and HRV and anxiety (beta = 0.26, p = 0.035). A combined model of smartphone and wearable features and self-reported mood provided the strongest prediction of depression. Conclusion: The current findings demonstrate that wearable devices may provide valuable sources of data in predicting symptoms of depression and anxiety, most notably data related to common measures of sleep.

Cognitive neuropsychological theory of antidepressant action: a modern-day approach to depression and its treatment

Depression is a leading cause of disability worldwide and improving its treatment is a core research priority for future programmes. A change in the view of psychological and biological processes, from seeing them as separate to complementing one another, has introduced new perspectives on pathological mechanisms of depression and treatment mode of action. This review presents a theoretical model that incorporated this novel approach, the cognitive neuropsychological hypothesis of antidepressant action. This model proposes that antidepressant treatments decrease the negative bias in the processing of emotionally salient information early in the course of antidepressant treatment, which leads to the clinically significant mood improvement later in treatment. The paper discusses the role of negative affective biases in the development of depression and response to antidepressant treatments. It also discusses whether the model can be applied to other antidepressant interventions and its potential translational value, including treatment choice, prediction of response and drug development.

A Randomized Controlled Trial of Attentional Control Training for Treating Alcohol Use Disorder

Background: There is consistent evidence that community and clinical samples of individuals with an alcohol use disorder (AUD) have attentional biases toward alcohol cues. The alcohol attentional control training program (AACTP) has shown promise for retraining these biases and decreasing alcohol consumption in community samples of excessive drinkers. However, there is a lack of evidence regarding the effectiveness of ACTP in clinical AUD samples. The main aim of the present study is to investigate whether primary pharmacological and psychological, evidence-based alcohol treatment can be enhanced by the addition of a gamified AACTP smartphone application for patients with an AUD. Design and Methods: The study will be implemented as a randomized controlled trial. A total of 317 consecutively enrolled patients with AUD will be recruited from alcohol outpatient clinics in Denmark. Patients will be randomized to one of three groups upon initiation of primary alcohol treatment: Group A: a gamified AACTP smartphone application + treatment as usual (TAU); Group B: a gamified AACTP sham-control application + TAU; or Group C: only TAU. Treatment outcomes will be assessed at baseline, post-treatment, and at 3- and 6-month follow-ups. Repeated measures MANOVA will be used to compare the trajectories of the groups over time on alcohol attentional bias, alcohol craving, and drinking reductions. It is hypothesized that Group A will achieve better treatment outcomes than either Group B or Group C. Perspectives: Because attentional bias for alcohol cues is proportional to the amount of alcohol consumed, and these biases are not addressed within current evidence-based treatment programs, this study is expected to provide new evidence regarding the effectiveness of the gamified AACTP in a clinical population. Furthermore, due to promising results found using AACTP in community samples of excessive drinkers, there is a high probability that the AACTP treatment in this study will also be effective, thereby allowing AACTP to be readily implemented in clinical settings. Finally, we expect that this study will increase the effectiveness of evidence-based AUD treatment and introduce a new, low-cost gamified treatment targeting patients with an AUD. Overall, this study is likely to have an impact at the scientific, clinical, and societal levels. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05102942?term=NCT05102942&draw=2&rank=1, identifier: NCT05102942.

Exploring the neural basis of fear produced by mental imagery: imaginal exposure in individuals fearful of spiders

Imaginal exposure, i.e. reducing fear using exposure to mental imagery, is a widely used psychological treatment technique for dysfunctional fears. Yet, little is known about its underlying neural mechanisms. The present study examines the neural basis of imaginal exposure using a novel experimental procedure consisting of repeated exposure to flashpoint mental imagery of phobic (spiders) and neutral (gloves) stimuli. Whether the 10 min long imaginal exposure procedure could reduce fear responses was examined one week later. Thirty participants fearful of spiders underwent the experimental procedure. Neural activity was assessed using functional magnetic resonance imaging (session 1). Subjective fear and skin conductance responses were measured throughout the study (sessions 1 and 2). Imaginal exposure evoked intense fear and heightened skin conductance responses, and indicated robust activation in several brain regions, including amygdala, midcingulate cortex and insula. Findings demonstrate that neural activity in fear-processing brain areas can be elicited solely by generating a mental image of a phobic stimulus, that is, in the absence of the percept. Relevant for treatment development, results reveal that a single 10 min session of brief exposures to flashpoint mental imagery can lead to lasting reductions in phobic fear at both the subjective and physiological levels. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Professionals' perceptions of the establishment of a specialized brief therapy unit in a district psychiatric centre - a qualitative study

Background

Increasing mental health problems and scarce treatment resources put pressure on mental health services to make innovations in service provision, such as developing differentiated services adapted to different needs. One innovation in differentiated service provision is brief or short-term treatment to patients with moderate mental health problems. Implementing a new unit in an organization usually faces many potential barriers and facilitators, and knowledge on how the professionals providing the services perceive the implementation of innovative approaches in mental health services is scarce. The aim of this study was therefore to explore the professionals’ perceptions of how the establishment of a specialized brief therapy unit had affected the organization, especially the everyday work in the outpatient clinics.

Methods

Eleven professionals, five men and six women, took part in individual interviews. All participants were between 40 and 60 years old and had leading or coordinating positions in the organization. Their professional backgrounds were within psychology, nursing and medicine, most of them specialists in their field. Data was analyzed according to Systematic text condensation.

Results

The professionals’ experiences represented four main themes: (1) The brief therapy unit was perceived as successful and celebrated. (2) The general outpatient clinics, on the other hand, were described as “forgotten”. (3) The establishment process had elucidated different views on treatment in the outpatient clinics - and had set off (4) a discussion regarding the criteria for prioritizing in mental health services.

Conclusion

Providing targeted treatment to patients with moderate mental health problems, while having a concurrent aim to solve broader problems in mental health services, entails a discussion regarding resource use and the appropriate level of treatment provision. Professionals should be more involved when innovative efforts are implemented, and the criteria for success must be conceptualized and evaluated. Longitudinal research on the implementation of innovative efforts in the services should include professionals’ and service users’ perspectives.

A Critical Review of Studies Assessing Interpretation Bias Towards Social Stimuli in People With Eating Disorders and the Development and Pilot Testing of Novel Stimuli for a Cognitive Bias Modification Training

People with eating disorders display a negative interpretation bias towards ambiguous social stimuli. This bias may be particularly relevant to young people with the illness due to the developmental salience of social acceptance and rejection. The overall aim of this study was to systematically develop and validate stimuli for a cognitive bias modification training to reduce a social rejection-related negative interpretation bias in young people with eating disorders. A mixed-methods design was used to achieve this aim. A review of the literature was conducted using EMBASE, MEDLINE, PsycINFO, Web of Science, and PubMed. Six studies were included in the review. Focus groups were held with patients with eating disorders, carers and healthcare professionals. Content analysis was used to identify key themes from the qualitative data. Based on these themes, a total of 339 scenarios were generated by the researchers. Salient themes identified from the focus group data included virtual rejection/exclusion, rejection associated with an aspect of the eating disorder, rejection triggered by ambiguous/benign comments or behaviors of others and rejection perceived when confiding in others. Patients rated these scenarios in terms of their age-relevance and emotional salience and 301 scenarios were included in the final stimulus set. These materials may be used by researchers conducting future experimental research into the potential benefits of interpretation bias training for young people with eating disorders.

The latent structure of the adult attachment interview: Large sample evidence from the collaboration on attachment transmission synthesis

The Adult Attachment Interview (AAI) is a widely used measure in developmental science that assesses adults’ current states of mind regarding early attachment-related experiences with their primary caregivers. The standard system for coding the AAI recommends classifying individuals categorically as having an autonomous, dismissing, preoccupied, or unresolved attachment state of mind. However, previous factor and taxometric analyses suggest that: (a) adults’ attachment states of mind are captured by two weakly correlated factors reflecting adults’ dismissing and preoccupied states of mind and (b) individual differences on these factors are continuously rather than categorically distributed. The current study revisited these suggestions about the latent structure of AAI scales by leveraging individual participant data from 40 studies (N = 3,218), with a particular focus on the controversial observation from prior factor analytic work that indicators of preoccupied states of mind and indicators of unresolved states of mind about loss and trauma loaded on a common factor. Confirmatory factor analyses indicated that: (a) a 2-factor model with weakly correlated dismissing and preoccupied factors and (b) a 3-factor model that further distinguished unresolved from preoccupied states of mind were both compatible with the data. The preoccupied and unresolved factors in the 3-factor model were highly correlated. Taxometric analyses suggested that individual differences in dismissing, preoccupied, and unresolved states of mind were more consistent with a continuous than a categorical model. The importance of additional tests of predictive validity of the various models is emphasized.

Effectiveness of digital psychological interventions for mental health problems in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

The effectiveness of digital psychological interventions in low-income and middle-income countries (LMICs) remains unclear. We aimed to systematically investigate the available evidence for digital psychological interventions in reducing mental health problems in LMICs.

METHODS

In this systematic review and meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane databases for articles published in English from database inception to March 9, 2020. We included randomised controlled trials investigating digital psychological interventions in individuals with mental health problems in LMICs. We extracted data on demographics, inclusion and exclusion criteria, details of the intervention, including the setting, digital delivery method, control group conditions, number of sessions, therapeutic orientation (eg, cognitive therapy or behaviour therapy), presence or absence of guidance, and length of follow-up, and statistical information to calculate effect sizes. If a study reported insufficient data to calculate effect sizes, the corresponding authors were contacted to provide data that could be aggregated. We did random-effects meta-analyses, and calculated the standardised mean difference in scores of digital psychological interventions versus control conditions (Hedges'g). Quality of evidence was assessed by use of the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was post-intervention mental health problems, as measured by self-reporting instruments or clinical interviews. This study is registered with PROSPERO, CRD42019137755.

FINDINGS

We identified 22 eligible studies that were included in the meta-analysis. The included studies involved a total of 4104 participants (2351 who received a digital psychological intervention and 1753 who were in the control group), and mainly focused on young adults (mean age of the study population was 20-35 years) with depression or substance misuse. The results showed that digital psychological interventions are moderately effective when compared with control interventions (Hedges'g 0·60 [95% CI 0·45-0·75]; Hedges'g with treatment as usual subgroup for comparison 0·54 [0·35-0·73]). Heterogeneity between studies was substantial (I²=74% [95% CI 60-83]). There was no evidence of publication bias, and the quality of evidence according to the GRADE criteria was generally high.

INTERPRETATION

Digital psychological interventions, which have been mostly studied in individuals with depression and substance misuse, are superior to control conditions, including usual care, and are moderately effective in LMICs. However, the considerable heterogeneity observed in our analysis highlights the need for more studies to be done, with standardised implementation of digital psychological intervention programmes to improve their reproducibility and efficiency. Digital psychological interventions should be considered for regions where usual care for mental health problems is minimal or absent.

FUNDING

None.

TRANSLATIONS

For the Persian, Chinese, Hindi, Portuguese, Bahasa, Turkish, Romanian, Spanish and Thai translations of the abstract see Supplementary Materials section.

[Digital Media in Psychotherapy - New Approaches and Perspectives in the Treatment of Trauma-Related Disorders]

This article provides an insight into novel approaches and perspectives using digital technologies in the treatment of trauma-related disorders. Therapy options for patients with trauma-related disorders are not easily available on a global scale and there is a search for new specific therapeutic strategies. In the first part of this article, examples of digital approaches are provided that are based on established analogue treatments and are designed mainly to increase availability and cost-effectiveness of these treatments. In the second part, the focus lies on digital treatments that employ novel approaches, which are e. g. informed by cognitive science, to specifically target particular symptoms in clinical populations after their development in lab studies. Examples given are visuospatial interventions used to reduce intrusive symptoms, or training programmes to increase levels of interference control (to control trauma-related stimuli), or to change automatic dysfunctional cognitions. These interventions will be presented with their respective theoretical frameworks, along with results from first (partially clinical) studies, which are promising concerning acceptance, applicability and effectiveness.

The role of childhood generalized anxiety in the internalizing cluster

BACKGROUND

Anxiety, depression and somatization (the internalizing cluster) are highly comorbid, prevalent and associated with significant individual and societal costs. Although prior studies have examined their natural course, there has been a little investigation into how symptoms unfold at the individual level. We examined the intraindividual (within-person) temporal patterning of symptom development and the impact of risk factors (sex, ethnicity, socioeconomic indicators, bullying victimization, child maltreatment) on symptom means and trajectories (between-person), comparing youth and parent reports.

METHOD

Over a 7-year interval from age 11 to 17, children (n = 669; 54% girls; 79% White) and parents (89% mothers) reported on symptoms of anxiety and depression from age 11 and somatization from age 13. Autoregressive latent trajectory models with structured residuals were used to uncouple within- and between-person sources of variance.

RESULTS

According to self-reports, generalized anxiety consistently predicted depression, while anxiety and depression consistently predicted somatization. Anxiety also had an indirect effect on somatization via depression. According to parent reports, there were several bidirectional effects between anxiety and depression and between depression and somatization. Experiences of abuse were consistent risk factors for self-reported internalizing symptoms, and across informants, girls had higher symptom means and rising trajectories compared to boys.

CONCLUSION

Generalized anxiety plays an important role in adolescent depressive and somatic symptoms. Primary prevention of anxiety may be warranted to curb symptom continuity and the development of comorbidity. Research is needed to determine whether self-reports of anxiety should be prioritized over parent reports and continued efforts are needed to reduce bullying and child maltreatment.

The scope of mental health research during the COVID-19 pandemic and its aftermath

The effects of the COVID-19 pandemic on population mental health are unknown. We need to understand the scale of any such impact in different sections of the population, who is most affected and how best to mitigate, prevent and treat any excess morbidity. We propose a coordinated and interdisciplinary mental health science response.

Examining the effectiveness of an online program to cultivate mindfulness and self-compassion skills (Mind-OP): Randomized controlled trial on Amazon's Mechanical Turk

OBJECTIVES

The demand for effective psychological treatments for depression, anxiety, and heightened stress is far outstripping their supply. Accordingly, internet delivered, self-help interventions offer hope to many people, as they can be easily accessed and at a fraction of the price of face-to-face options. Mindfulness and self-compassion are particularly exciting approaches, as evidence suggests interventions that cultivate these skills are effective in reducing depression, anxiety, and heightened stress. We examined the effectiveness of a newly developed program that combines mindfulness, self-compassion, and goal-setting exercises into a brief self-guided intervention (Mind-OP). The secondary aim of this study was to investigate the feasibility of conducting a randomized-controlled trial entirely on a popular crowdsourcing platform, Amazon's Mechanical Turk (MTurk).

METHODS

We randomized 456 participants reporting heightened depression, anxiety, or stress to one of two conditions: the 4-week Mind-OP intervention (n = 227) or to an active control condition (n = 229) where participants watched nature videos superimposed onto relaxing meditation music for four consecutive weeks. We administered measures of anxiety, depression, perceived stress, dispositional and state mindfulness, self-compassion, and nonattachment.

RESULTS

Intent-to-treat and per-protocol analyses revealed that, compared to participants in the control condition, participants in the Mind-OP intervention condition reported significantly less anxiety and stress at the end of the trial, as well as significantly greater mindfulness, self-compassion, and nonattachment.

CONCLUSIONS

Mind-OP appears effective in reducing anxiety symptoms and perceived stress among MTurk participants. We highlight issues (e.g., attrition) related to feasibility of conducting randomized trials on crowdsourcing platforms such as MTurk.

Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial

IMPORTANCE

Health anxiety is a common and often chronic mental health problem associated with distress, substantial costs, and frequent attendance throughout the health care system. Face-to-face cognitive behavior therapy (CBT) is the criterion standard treatment, but access is limited.

OBJECTIVE

To test the hypothesis that internet-delivered CBT, which requires relatively little resources, is noninferior to face-to-face CBT in the treatment of health anxiety.

DESIGN, SETTING, AND PARTICIPANTS

This randomized noninferiority clinical trial with health economic analysis was based at a primary care clinic and included patients with a principal diagnosis of health anxiety who were self-referred or referred from routine care. Recruitment began in December 10, 2014, and the last treatment ended on July 23, 2017. Follow-up data were collected up to 12 months after treatment. Analysis began October 2017 and ended March 2020.

INTERVENTIONS

Patients were randomized (1:1) to 12 weeks of internet-delivered CBT or to individual face-to-face CBT.

MAIN OUTCOMES AND MEASURES

Change in health anxiety symptoms from baseline to week 12. Analyses were conducted from intention-to-treat and per-protocol (completers only) perspectives, using the noninferiority margin of 2.25 points on the Health Anxiety Inventory, which has a theoretical range of 0 to 54.

RESULTS

Overall, 204 patients (mean [SD] age, 39 [12] years; 143 women [70%]) contributed with 2386 data points on the Health Anxiety Inventory over the treatment period. Of 204 patients, 102 (50%) were randomized to internet-delivered CBT, and 102 (50%) were randomized to face-to-face CBT. The 1-sided 95% CI upper limits for the internet-delivered CBT vs face-to-face CBT difference in change were within the noninferiority margin in the intention-to-treat analysis (B = 0.00; upper limit: 1.98; Cohen d = 0.00; upper limit: 0.23) and per-protocol analysis (B = 0.01; upper limit: 2.17; Cohen d = 0.00; upper limit: 0.25). The between-group effect was not moderated by initial symptom level, recruitment path, or patient treatment preference. Therapists spent 10.0 minutes per patient per week in the online treatment vs 45.6 minutes for face-to-face CBT. The net societal cost was lower in the online treatment (treatment period point difference: $3854). There was no significant group difference in the number of adverse events, and no serious adverse event was reported.

CONCLUSIONS AND RELEVANCE

In this trial, internet-delivered CBT appeared to be noninferior to face-to-face CBT for health anxiety, while incurring lower net societal costs. The online treatment format has potential to increase access to evidence-based treatment for health anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02314065.

Developing thinking around mental health science: the example of intrusive, emotional mental imagery after psychological trauma

INTRODUCTION

One route to advancing psychological treatments is to harness mental health science, a multidisciplinary approach including individuals with lived experience and end users (e.g., Holmes, E. A., Craske, M. G., & Graybiel, A. M. (2014). Psychological treatments: A call for mental-health science. Nature, 511(7509), 287-289. doi:10.1038/511287a). While early days, we here illustrate a line of research explored by our group-intrusive imagery-based memories after trauma.

METHOD/RESULTS

We illustrate three possible approaches through which mental health science may stimulate thinking around psychological treatment innovation. First, focusing on single/specific target symptoms rather than full, multifaceted psychiatric diagnoses (e.g., intrusive trauma memories rather than all of posttraumatic stress disorder). Second, investigating mechanisms that can be modified in treatment (treatment mechanisms), rather than those which cannot (e.g., processes only linked to aetiology). Finally, exploring novel ways of delivering psychological treatment (peer-/self-administration), given the prevalence of mental health problems globally, and the corresponding need for effective interventions that can be delivered at scale and remotely for example at times of crisis (e.g., current COVID-19 pandemic).

CONCLUSIONS

These three approaches suggest options for potential innovative avenues through which mental health science may be harnessed to recouple basic and applied research and transform treatment development.

Exposure to food in anorexia nervosa and brain correlates of food-related anxiety: findings from a pilot study

BACKGROUND

Although the primary target of treatment for anorexia nervosa (AN) is weight gain, established psychological interventions focus on maintaining factors of AN, and do not specifically address eating behaviours. We have previously reported results of a case series investigating in-vivo food exposure in AN, demonstrating the feasibility and acceptability of this treatment together with evidence of significant clinical change (Cardi, Leppanen, Mataix-Cols, Campbell, & Treasure, 2019). The current study examined the neural circuitry of food-related anxiety.

METHODS

We examined neural reactivity (fMRI) to food images pre- and post-food exposure therapy (n=16), and compared it to a group of healthy control participants (HC n=21) who were scanned on two occasions.

RESULTS

Prior to treatment, the AN group (compared to HC) showed less reactivity in the anterior cingulate cortex (ACC). Following exposure treatment, patients (compared to HC), show increased activity in the dorsolateral prefrontal cortex, decreased activity in the superior parietal lobe and no differences in the ACC. The level of activation of the insula (pre-treatment) predicted the degree of post-treatment reduction in self-reported food anxiety in AN. Changes in food-related anxiety were also associated with changes in neural activation in a cluster located in the middle temporal gyrus/lateral parietal cortex.

LIMITATIONS

The primary limitations of this work are the small sample size and lack of patient comparison group.

CONCLUSIONS

Exposure to food in AN may be associated with changes in neural circuitries implicated in emotion regulation and attentional processes. However, these findings need replication in larger and controlled studies.

Mood Homeostasis, Low Mood, and History of Depression in 2 Large Population Samples

IMPORTANCE

Existing therapeutic options are insufficient to tackle the disease burden of depression, and new treatments are sorely needed. Defining new psychotherapeutic targets is challenging given the paucity of coherent mechanistic explanations for depression.

OBJECTIVE

To assess whether mood homeostasis (ie, the stabilization of one's mood by engaging in mood-modifying activities) is a possible new therapeutic target by testing the hypothesis that people with low (vs high) mean mood and people with (vs without) a history of depression have impaired mood homeostasis.

DESIGN, SETTING, AND PARTICIPANTS

The quantitative association between mood and daily activities was computed in 2 large case-control studies based on the 58sec data set (collected from December 1, 2012, to May 31, 2014, and analyzed from April 1 to 30, 2019), and the World Health Organization Study on Global Aging and Adult Health (WHO SAGE) data set (collected from January 1, 2007, to December 31, 2010, and analyzed from June 1 to 30, 2019). The 58sec data set consists of self-enrolled participants from high-income countries. The WHO SAGE data set consists of nationally representative participants in low- and middle-income countries recruited via cluster sampling.

MAIN OUTCOMES AND MEASURES

The main outcome (defined before data analysis) was the difference in mood homeostasis between people with high vs low mean mood (58sec data) and between people with vs without a history of depression (WHO SAGE data).

RESULTS

A total of 28 212 participants from the 58sec data set (65.8% female; mean [SD] age, 28.1 [9.0] years) and 30 116 from the WHO SAGE data set (57.0% female; mean [SD] age, 57.8 [14.7] years) were included, for an overall study population of 58 328 participants. Mood homeostasis was significantly lower in people with low (vs high) mean mood (0.63 [95% CI, 0.45 to 0.79] vs 0.96 [95% CI, 0.96 to 0.98]; P < .001) and in people with (vs without) a history of depression (0.03 [95% CI, -0.26 to 0.24] vs 0.68 [95% CI, 0.55 to 0.75]; P < .001). In dynamic simulations, lower mood homeostasis led to more depressive episodes (11.8% vs 3.8% yearly risk; P < .001) that lasted longer (4.19 vs 2.90 weeks; P = .006).

CONCLUSIONS AND RELEVANCE

In this study, mood homeostasis appeared to have been impaired in people with low mood and in those with a history of depression. Mood homeostasis may therefore provide new insights to guide the development of treatments for depression.

Frequencies and Predictors of Negative Effects in Routine Inpatient and Outpatient Psychotherapy: Two Observational Studies

Negative effects of psychotherapy (NEP) include side effects, malpractice, and unethical behavior. Its setting-specific frequencies and predictors are mostly unknown. The two presented studies aim to investigate NEP and its predictors systematically across different treatment settings. In study 1, N = 197 patients of a German outpatient center were recruited, on average, 3.76 years after the termination of psychotherapy. In study 2, data from N = 118 patients of two German inpatient clinics were collected at admission (t₀), discharge (t₁), and 9-month follow-up (t₂). All participants evaluated the negative effects of their previous out- or inpatient psychotherapy with the Inventory for the Balanced Assessment of Negative Effects in Psychotherapy and a priori hypothesized predictors. At least one side effect was reported by 37.3% of inpatients (t₂) and 15.2% of outpatients. At least one case of malpractice and unethical behavior was reported by 28.8% of inpatients (t₂) and 7.1% of outpatients. Inpatients reported significantly more side effects (U = 14347, z = 4.70, p < 0.001, r = 0.26) and malpractice and unethical behavior (U = 14168, z = 5.21, p < 0.001, r = 0.29) than outpatients. Rates of severe malpractice in the form of breaking confidentiality and physical and sexual abuse were less than 1% in both settings. Predictors of side effects were prior experience with psychotherapy and current interpersonal difficulties in the outpatient setting and higher motivation for psychotherapy (t₀) in the inpatient setting. Predictors of malpractice and unethical behavior were younger age in the outpatient setting and poor therapeutic alliance, prior negative experience with malpractice and unethical behavior, and higher outcome expectations in the inpatient setting. NEP are common in both, in- and outpatient settings. Inpatients are at higher risk for the NEP than outpatients. To safeguard patients’ wellbeing, the systematic assessment and distinction of side effects and malpractice and unethical behavior should gain more attention in research and clinical practice.

Harnessing Mental Imagery and Enhancing Memory Specificity: Developing a Brief Early Intervention for Depressive Symptoms in Adolescence

Background

Treatment innovation for depressive symptoms in adolescence is urgently needed. Adult research suggests interventions targeting underlying cognitive mechanisms, such as dysfunctional mental imagery and overgeneral memory, are promising. Here, we describe and evaluate in a case series a brief imagery-based intervention for depressive symptoms that targets these cognitive mechanisms.

Methods

Nine participants completed the four-session intervention, whose principle components were imagery rescripting and memory specificity training. Questionnaires and experimental tasks (assessing symptomatology and cognitive mechanisms) were administered at three time points: pre-intervention, post-intervention and 3-month follow-up.

Results

The intervention was feasible to deliver and acceptable to participants. There was a large reduction in depression symptom scores from pre to post intervention (d = 1.32; 67% showed reliable improvement, RI) and this was maintained at follow-up (d = 1.46; RI = 75%). There were also reductions in anxiety (post: d = 1.15, RI = 44%; follow-up: d = 1.67, RI = 63%), increases in self-esteem (post: d = − 0.70, RI = 44%; follow-up: d = − 1.20, RI = 50%) and noteworthy changes in memory specificity (post: d = − 1.80, RI = 67%; follow-up: d = − 0.94, RI = 63%).

Conclusions

This is the first study to use imagery rescripting and memory specificity training in adolescence. Initial evidence is provided that the intervention is acceptable and may have clinical utility. Future randomised controlled trials are needed to further assess the intervention.

Suicidal Imagery in Borderline Personality Disorder and Major Depressive Disorder

A better understanding of suicidal behavior is important to detect suicidality in at-risk populations such as patients with borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). Suicidal tendencies are clinically assessed by verbal thoughts rather than by specifically asking about mental images. This study examines whether imagery and verbal thoughts about suicide occur and differ between patients with BPD with and without comorbid PTSD compared to patients with MDD (clinical controls). All patient groups experienced suicide-related images. Patients with BPD with comorbid PTSD reported significantly more vivid images than patients with MDD. Severity of suicidal ideation, number of previous suicide attempts, and childhood traumata were significantly associated with suicidal imagery across all patient groups. The authors demonstrate for the first time that suicide-related mental imagery occurs in BPD and is associated with suicidal ideation. This finding highlights the importance of assessing mental imagery related to suicide in clinical practice.

Exposure-based cognitive behavior therapy for anxiety related to asthma: A feasibility study with multivariate baseline design

In the presence of asthma, the risk of having an anxiety disorder is increased twofold. The few trials conducted on cognitive behavior therapy (CBT) for anxiety and asthma have mainly targeted panic disorder, and with mixed results. Experimental laboratory research indicates that increased anxiety may lead to hypervigilance toward asthma. Hence, fear and avoidance associated with increased anxiety due to asthma may be an important treatment target. A treatment that learn participants to differentiate between anxiety and asthma through gradual exposure to situations that risk triggering anxiety for asthma may be a possible avenue. As a first step to investigate this issue further, we developed a 10-week exposure-based CBT protocol for anxiety related to asthma and tested it in six participants using multivariate baseline design with repeated assessments throughout treatment. All participants reported satisfaction with treatment, as well as subjective overall improvement after treatment. Visual analysis, using graphs over each individual's trajectory, as well as potential efficacy on group level analyzing standardized mean change, indicated improvements in important outcomes. We conclude that exposure-based CBT is feasible and may improve anxiety related to asthma. Further investigation under randomized controlled trial conditions is warranted.

A complex systems approach to the study of change in psychotherapy

BACKGROUND

A growing body of research highlights the limitations of traditional methods for studying the process of change in psychotherapy. The science of complex systems offers a useful paradigm for studying patterns of psychopathology and the development of more functional patterns in psychotherapy. Some basic principles of change are presented from subdisciplines of complexity science that are particularly relevant to psychotherapy: dynamical systems theory, synergetics, and network theory. Two early warning signs of system transition that have been identified across sciences (critical fluctuations and critical slowing) are also described. The network destabilization and transition (NDT) model of therapeutic change is presented as a conceptual framework to import these principles to psychotherapy research and to suggest future research directions.

DISCUSSION

A complex systems approach has a number of implications for psychotherapy research. We describe important design considerations, targets for research, and analytic tools that can be used to conduct this type of research.

CONCLUSIONS

A complex systems approach to psychotherapy research is both viable and necessary to more fully capture the dynamics of human change processes. Research to date suggests that the process of change in psychotherapy can be nonlinear and that periods of increased variability and critical slowing might be early warning signals of transition in psychotherapy, as they are in other systems in nature. Psychotherapy research has been limited by small samples and infrequent assessment, but ambulatory and electronic methods now allow researchers to more fully realize the potential of concepts and methods from complexity science.

A single case series using visuospatial task interference to reduce the number of visual intrusive memories of trauma with refugees

The current worldwide so-called "refugee crisis" has led to an unprecedented increase in migration globally. Because of stigma and language barriers, mental health care for refugees is limited. There is a need for novel, scalable psychological interventions. We investigated whether a brief behavioural intervention involving a memory reminder cue and Tetris gameplay on a smartphone reduces intrusive memories in refugees using a single case (N = 4) ABAB withdrawal design. The baseline phase (A) included a no-intervention week; the intervention phase (B) included an in-person session with the researchers, comprised of the behavioural intervention followed by self-guided use in daily life the following week. All participants reported a decrease in intrusive memories after the intervention, as well as functional improvements (e.g., in concentration). Importantly, participants rated the intervention as feasible and acceptable. As one in-person session was effective in persistent intrusion reduction, ABAB proved not to be the optimal design as intrusions did not rebound in the withdrawal phase. Findings are promising and highlight the need for further evaluation of novel interventions for mental health problems in refugees.

An mHealth intervention for the treatment of patients with an eating disorder: A multicenter randomized controlled trial

OBJECTIVE

The current multicentre randomized controlled trial assessed the clinical efficacy of a combined mHealth intervention for eating disorders (EDs) based on cognitive behavioral therapy (CBT).

METHOD

A total of 106 ED patients from eight different public and private mental health services in Spain were randomly assigned to two parallel groups. Patients of the experimental group (N = 53) received standard face-to-face CBT plus a mobile intervention through an application called "TCApp," which provides self-monitoring and an online chat with the therapist. The control group (N = 53) received standard face-to-face CBT only. Patients completed self-report questionnaires on ED symptomatology, anxiety, depression, and quality of life, before and after treatment.

RESULTS

Significant reductions in primary and secondary outcomes were observed for participants of both groups, with no differences between groups. Results also suggested that the frequency with which patients attended their referral mental health institution after the intervention was lower for patients in the experimental group than for those in the control group.

DISCUSSION

The current study showed that CBT can help to reduce symptoms relating to ED, regardless of whether its delivery includes online components in addition to traditional face-to-face treatment. Besides, the additional component offered by the TCApp does not appear to be promising from a purely therapeutic perspective but perhaps as a cost-effective tool, reducing thus the costs and time burden associated with weekly visits to health professionals.

Translating big data to better treatment in bipolar disorder - a manifesto for coordinated action

Bipolar disorder (BD) is a major healthcare and socio-economic challenge. Despite its substantial burden on society, the research activity in BD is much smaller than its economic impact appears to demand. There is a consensus that the accurate identification of the underlying pathophysiology for BD is fundamental to realize major health benefits through better treatment and preventive regimens. However, to achieve these goals requires coordinated action and innovative approaches to boost the discovery of the neurobiological underpinnings of BD, and rapid translation of research findings into development and testing of better and more specific treatments. To this end, we here propose that only a large-scale coordinated action can be successful in integrating international big-data approaches with real-world clinical interventions. This could be achieved through the creation of a Global Bipolar Disorder Foundation, which could bring government, industry and philanthropy together in common cause. A global initiative for BD research would come at a highly opportune time given the seminal advances promised for our understanding of the genetic and brain basis of the disease and the obvious areas of unmet clinical need. Such an endeavour would embrace the principles of open science and see the strong involvement of user groups and integration of dissemination and public involvement with the research programs. We believe the time is right for a step change in our approach to understanding, treating and even preventing BD effectively.

Understanding young peoples' and family members' views of treatment for first episode psychosis in a randomised controlled trial (MAPS)

BACKGROUND

There is limited evidence to inform treatment decision-making in adolescents experiencing first episode psychosis (FEP). In the MAPS trial (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with FEP received either antipsychotic medication (AP), psychological intervention (PI), or both. We investigated treatment views of young people and family members across each treatment arm of MAPS.

METHODS

Thirteen adolescents participating in MAPS and eighteen family members attended in-depth audio-recorded interviews to discuss trial treatments. Interviews were analysed using inductive Thematic Analysis, identifying salient themes across these accounts.

FINDINGS

Family members in particular reported an urgent need for treatment regardless of type. Both AP and PI were broadly viewed as acceptable treatment approaches, but for differing reasons which participants weighed against a range of concerns. AP were often seen to reduce symptoms of psychosis, though participants expressed concerns about side effects. PI were viewed as interactive treatment approaches that helped improve understanding of psychosis and enhanced coping, although some found PI emotionally and cognitively challenging. Combining treatments was seen to maximise benefits, with a perceived interaction whereby AP facilitated engagement with PI.

INTERPRETATION

Acceptability of and engagement with treatments for FEP may differ between individual young people and their family/carers. In order to be able to offer fully informed choices, and determine an optimum treatment approach for young people with FEP, definitive trial evidence should be established to determine wanted and unwanted treatment impacts.

FUNDING

NIHR HTA programme (project number 15/31/04).

Clinicians' views of treatment types for first episode psychosis delivered in a randomised controlled trial (MAPS)

BACKGROUND

Clinicians' treatment beliefs could affect the feasibility of delivering different treatments in a randomised controlled trial (RCT). In MAPS (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with first episode psychosis (FEP) were randomly allocated to receive either antipsychotic medication (AP), psychological intervention (cognitive behavioural therapy [CBT] and family intervention [FI]), or both. We conducted a nested qualitative study to investigate clinicians' views of these treatments.

METHODS

Purposive sampling identified seventeen clinicians from CAMHS and Early Intervention services with prescribing responsibilities for 14-18 year olds at three participating MAPS sites. Individual participants were interviewed to examine their views of treatments in the MAPS trial. Interview transcripts were analysed using inductive Thematic Analysis.

FINDINGS

Clinicians viewed the decision to refer adolescents to the MAPS trial as requiring careful clinical judgement. Assessment complexity and diagnostic uncertainty had to be balanced against the urgency for treatment to reduce risk and distress. Underlying influences including duty of care and treatment beliefs underpinned decisions. Clinicians consistently valued AP as the primary treatment for FEP, with CBT and/or FI seen as helpful secondary treatment options. Nevertheless, the potential harms of prescribing AP, or not, to such a young population were highlighted as being of concern in treatment decision-making, and fostered reluctance to refer into a RCT.

INTERPRETATION

The design and delivery of RCTs involving young people experiencing FEP should consider the views of responsible clinicians, recognising that perceived treatment urgency, limitations in diagnostic precision, and existing treatment beliefs may influence trial processes.

FUNDING

NIHR HTA programme (project number 15/31/04).

Development of a transdiagnostic, low-intensity, psychological intervention for common adolescent mental health problems in Indian secondary schools

BACKGROUND

The PRIDE programme aims to establish a suite of transdiagnostic psychological interventions organised around a stepped care system in Indian secondary schools. This paper describes the development of a low-intensity, first-line component of the PRIDE model.

METHOD

Contextual and global evidence informed an intervention 'blueprint' with problem solving as the primary practice element. Successive iterations were tested and modified across two pilot cohort studies (N = 45; N = 39). Participants were aged 13-20 years and presenting with elevated mental health symptoms in New Delhi schools.

RESULTS

The first iteration of the intervention, based on a guided self-help modality, showed promising outcomes and user satisfaction when delivered by psychologists. However, delivery was not feasible within the intended 6-week schedule, and participants struggled to use materials outside 'guidance' sessions. In Pilot 2, a modified counsellor-led problem-solving intervention was implemented by less experienced counsellors over a 3-4 week schedule. Outcomes were maintained, with indications of enhanced feasibility and acceptability. High demand was observed across both pilots, leading to more stringent eligibility criteria and a modified sensitisation plan.

DISCUSSION

Findings have shaped a first-line intervention for common adolescent mental health problems in low-resource settings. A forthcoming randomised controlled trial will test its effectiveness.

Change Processes in Cognitive Therapy for Social Anxiety Disorder Delivered in Routine Clinical Practice

Background

Most studies examining processes of change in psychological therapy for social anxiety disorder (SAD) have analysed data from randomised controlled trials in research settings.

Method

To assess whether these findings are representative of routine clinical practice, we analysed audit data from two samples of patients who received Cognitive Therapy for SAD (total N = 271). Three process variables (self-focused attention, negative social cognitions, and depressed mood) were examined using multilevel structural equation models.

Results

Significant indirect effects were observed for all three variables in both samples, with negative social cognitions showing the strongest percent mediation effect. ‘Reversed’ relationships, where social anxiety predicted subsequent process variable scores, were also supported.

Conclusion

The findings suggest the processes of change in this treatment may be similar between research trials and routine care.

The three process variables examined showed significant indirect effects on subsequent social anxiety.

There was evidence of a bidirectional relationship between process and outcome.

Results are consistent with the theoretical model underpinning the treatment.

The change processes of this treatment in routine practice may be similar to those found in research trials.