CBT at the Crossroads: The Rise of Transdiagnostic Treatments

Factors Associated with Prospective Acceptability and Preferences for Unified Transdiagnostic Cognitive-Behavioral Treatments and Group Therapy in the Portuguese General Population

Group transdiagnostic cognitive-behavioral therapy (CBT) offers a promising solution for limited mental health access in Portugal. Understanding barriers to patient adherence is crucial for successful implementation. This study aimed to characterize the prospective acceptability and preferences for unified transdiagnostic CBT and group therapy in the Portuguese general population and explore their correlates. A sample of 243 participants (18-88 years old), recruited online, completed an online survey collecting information on sociodemographic and clinical characteristics, acceptability of transdiagnostic CBT treatments, specifically of Unified Protocol (UP), acceptability of group therapy, therapeutic format preferences, beliefs about group therapy and help-seeking attitudes. Most participants were receptive to and perceived as useful both unified transdiagnostic CBT and group therapy. Overall, participants presented significantly more favorable attitudes than unfavorable attitudes toward unified transdiagnostic CBT and group therapy (p < .001). Multivariate analyses revealed that (1) favorable attitudes toward transdiagnostic treatments were negatively associated with being employed and positively associated with living in an urban area, and higher efficacy scores; (2) unfavorable attitudes toward transdiagnostic treatments were positively associated with being married/cohabitating and negatively associated with vulnerability scores; (3) being female, living in an urban area, and higher efficacy and myth scores emerged as positive predictors of favorable attitudes toward group therapy; and (4) efficacy and vulnerability scores and help-seeking propensity emerged as negative predictors of unfavorable attitudes toward group therapy. These findings highlight the importance of delineating strategies to increase knowledge and acceptance of unified transdiagnostic CBT and group therapy in the Portuguese population, addressing specific individual characteristics.

Targeting metacognitive change mechanisms in acute inpatients with psychotic symptoms: feasibility and acceptability of a modularized group intervention

Emerging evidence suggests the usefulness of psychological interventions targeting metacognitive change mechanisms in patients experiencing psychosis. Although many of these patients are treated in acute psychiatric contexts, only few studies have adapted such interventions for acute inpatient settings. The present study aimed to assess the feasibility, acceptability, and preliminary clinical outcomes of a novel modularized group intervention focusing on different aspects of metacognitive change mechanisms. In particular, the intervention aims to reduce patients' acute symptoms by enhancing cognitive insight and to relieve distress via cognitive defusion (i.e. coping). A sample of 37 participants with acute psychosis received up to nine sessions of the intervention. Baseline and post-intervention assessments were conducted for general psychopathology, psychotic symptoms, global functioning, and symptom distress. Measures of change mechanisms were assessed before and after the respective treatment module. Participants' experiences were explored in feedback questionnaires and interviews. Recruitment, retention, and attendance rate met the pre-set feasibility benchmark of 80%. The intervention was well received by participants, who emphasised the group's clear structure, positive atmosphere, and helpful contents. Response rates were high and linear mixed models revealed significant medium-to-large time effects on all clinical outcomes. As expected, increase in hypothesised change mechanisms cognitive insight and decrease in cognitive fusion was found. However, the uncontrolled design limits interpreting clinical effects. The study provides evidence that an intervention based on a metacognitive model is feasible and acceptable for acute inpatients with psychosis. Positive results on clinical outcomes and change mechanisms warrant further exploration in a randomized controlled trial.

Depressed mood as a transdiagnostic target relevant to anxiety and/or psychosis: a scoping review protocol

INTRODUCTION

Depressed mood is a psychological state characterised by sadness or loss of interest in activities. Depressed mood is a highly prevalent symptom across major mental disorders. However, there is limited understanding of the burden and management of comorbid depressed mood across major mental disorders. Therefore, this scoping review aims to summarise knowledge on depressed mood among persons with anxiety and/or psychosis. The specific aims are to describe the epidemiology and risk factors of depressed mood as a transdiagnostic target among persons with anxiety and/or psychosis, to identify commonly used outcome measures for depressed mood and to outline initial evidence of psychometric robustness and to identify and summarise the effectiveness of commonly applied depressed mood modification interventions. Our hope is that the proposed review will provide insights into the burden of depressed mood in persons with anxiety and psychosis and help to identify evidence gaps and recommendations for future research.

METHODS AND ANALYSIS

This scoping review will be conducted per Arksey and O'Malley's framework. We will first search for peer-reviewed articles and grey literature published from 2004 to 2023 in PubMed, Scopus, Web of Science, Africa-Wide Information, CINAHL, PsycINFO, Academic Search Premier, Humanities International Complete, Sabinet, SocINDEX, Open Grey and Google Scholar. We will include articles reporting depressed mood (subthreshold depression) among persons with anxiety and/or psychosis. Studies recruiting participants meeting depression diagnostic criteria and those published in non-English languages will be excluded. Two independent researchers will extract the data. We will analyse and chart data collaboratively with researchers with lived experiences of depressed mood.

ETHICS AND DISSEMINATION

This study does not require ethical approval as it is a literature review. The results will be submitted for publication in a peer-reviewed journal.

Ultra-brief acceptance & commitment therapy for inpatients with psychosis - a single-case experimental design investigating processes of change

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments are not routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient setting. The first aim of the current study was to examine treatment effects of a brief form of Acceptance and Commitment Therapy on outcomes valued by the treatment recipients. The second aim was to explore hypothetical processes of change in relation to outcomes over time. Three people with primary psychosis were treated for two to four sessions. A replicated single-case experimental design with multiple baselines across subjects (Clinical Trials registration number ID NCT04704973) was employed to examine treatment effects. The Personal Questionnaire (PQ) was used as primary outcome, symptom believability and preoccupation as proposed processes of change. Data were analyzed using visual inspection, calculation of Tau-U values, and cross-lagged correlation. All participants improved significantly on PQ and the symptom preoccupation measure. Two improved significantly on the symptom believability measure. Cross-lagged correlation analyses showed no clear mediation. Change in proposed processes of change and primary outcome predominantly happened concomitantly, although patterns of results reflected individual differences.

A One-Arm Pilot Trial of a Telehealth CBT-Based Group Intervention Targeting Transdiagnostic Risk for Emotional Distress

The COVID-19 pandemic had a significant impact on mental health, straining an already overburdened healthcare system. A modular, transdiagnostic approach to treating psychopathology may be ideal to target common transdiagnostic risk factors for emotional distress and related disorders likely to be impacted by circumstances related to this once-in-a-lifetime environmental stressor. Anxiety sensitivity (AS), or fear of anxious arousal, intolerance of uncertainty (IU), or distress when confronted with uncertainty, and loneliness are three transdiagnostic risk factors impacted by the pandemic and robust predictors of emotional distress beyond that. We completed a pilot feasibility, acceptability, and utility trial of Coping Crew, our group, telehealth-delivered transdiagnostic treatment protocol in 17 participants who completed the intervention (M age = 22.00, SD = 4.46; 71% female). The intervention and study protocol were feasible to deliver and were rated as acceptable and useful to address intervention targets. Evidence was mixed regarding feasibility, acceptability, and usefulness of the mobile app component. Sixteen of 17 participants (94%) completed at least one survey a day on 80% of the days but only 6 participants (35%) completed at least 80% of the mobile app surveys delivered over the course of the intervention. Most participants rated use of the app as acceptable and relevant to psychological improvements made due to the intervention. Sizeable effect size reductions in transdiagnostic risk factors were found at post-intervention and maintained at 1- and 3-month follow-up, supporting next steps in the development of this modular transdiagnostic treatment.

Universal, school-based transdiagnostic interventions to promote mental health and emotional wellbeing: a systematic review

OBJECTIVE

This systematic review aims to evaluate the effectiveness of universal school-based transdiagnostic interventions in promoting the mental health of children and adolescents. It compares and discusses interventions targeting the prevention of mental disorders versus the promotion of mental health. Additionally, the roles of teachers and psychologists as intervention conductors are examined.

METHODS

A comprehensive search of the Psycinfo, Pubmed, and Web of Science databases was conducted without any time restrictions to identify relevant literature on universal school-based transdiagnostic interventions promoting children and adolescents' mental health.

RESULTS AND DISCUSSION

The findings reveal that universal school-based transdiagnostic promotion/prevention programs have a small to medium overall effect size. These interventions demonstrate a broad coverage of different aspects of children and adolescents' mental health. However, the relative effectiveness of teacher-led versus psychologist-led interventions remains unclear. Interventions focused on preventing mental disorders exhibit a higher effect size, albeit on a narrower range of mental health aspects for children and adolescents.

SIGNIFICANCE

This study enhances our understanding of universal school-based transdiagnostic interventions and their impact on children and adolescents' mental health. Further research is needed to elucidate the comparative efficacy of teacher-led and psychologist-led interventions and to explore the specific dimensions of mental health targeted by these interventions.

Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care

INTRODUCTION

A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings.

MATERIALS AND METHODS

Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university.

RESULTS

Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion.

CONCLUSIONS

Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.

TONI - One for all? Participatory development of a transtheoretic and transdiagnostic online intervention for blended care

Background

Internet-based interventions offer a way to meet the high demand for psychological support. However, this setting also has disadvantages, such as the lack of personal contact and the limited ability to respond to crises. Blended care combines Internet-based interventions with face-to-face psychotherapy and merges the benefits of both settings. To ensure the uptake of blended care in routine care, Internet-based interventions need to be suitable for different therapeutic approaches and mental disorders.

Objective

This paper describes the participatory development process of the Internet-based intervention "TONI" using a common therapeutic language and content on various transdiagnostic topics to be integrated into routine outpatient psychotherapy.

Methods

To develop this intervention in a participatory manner, we followed the Integrate, Design, Assess, and Share (IDEAS) framework. In a multilevel development process, we used a combination of interviews, focus groups, and proofreading to optimally tailor online modules to routine outpatient psychotherapy. Building on well-established cognitive-behavioral online content, we included expert interviews with psychodynamic (n = 20) and systemic psychotherapists (n = 9) as well as focus groups with psychotherapists of different approaches (n = 10) and persons with lived experience of mental illness (PWLE; n = 10).

Results

We describe the development process of TONI step-by-step, outlining the specific requirements that therapists from different therapeutic approaches as well as PWLE have and how we implemented them in our intervention. This includes the content and specific exercises in the online modules, aspects of data protection, language, design, and usability.

Conclusion

Internet-based interventions that use a common therapeutic language and address therapeutic principles across different approaches have the potential to advance digitalization in psychotherapy. Involving psychotherapists and PWLE in intervention development may positively impact acceptance and usage in practice. This study shows how participatory intervention development involving both psychotherapists and PWLE can be carried out.

A systematic review and meta-analysis of transdiagnostic cognitive behavioural therapies for emotional disorders

Transdiagnostic cognitive behavioural psychotherapy (TD-CBT) may facilitate the treatment of emotional disorders. Here we investigate short- and long-term efficacy of TD-CBT for emotional disorders in individual, group and internet-based settings in randomized controlled trials (PROSPERO CRD42019141512). Two independent reviewers screened results from PubMed, MEDLINE, PsycINFO, Google Scholar, medRxiv and OSF Preprints published between January 2000 and June 2023, selected studies for inclusion, extracted data and evaluated risk of bias (Cochrane risk-of-bias tool 2.0). Absolute efficacy from pre- to posttreatment and relative efficacy between TD-CBT and control treatments were investigated with random-effects models. Of 56 identified studies, 53 (6,705 participants) were included in the meta-analysis. TD-CBT had larger effects on depression (g = 0.74, 95% CI = 0.57-0.92, P < 0.001) and anxiety (g = 0.77, 95% CI = 0.56-0.97, P < 0.001) than did controls. Across treatment formats, TD-CBT was superior to waitlist and treatment-as-usual. TD-CBT showed comparable effects to disorder-specific CBT and was superior to other active treatments for depression but not for anxiety. Different treatment formats showed comparable effects. TD-CBT was superior to controls at 3, 6 and 12 months but not at 24 months follow-up. Studies were heterogeneous in design and methodological quality. This review and meta-analysis strengthens the evidence for TD-CBT as an efficacious treatment for emotional disorders in different settings.

Using the 'Leapfrog' Design as a Simple Form of Adaptive Platform Trial to Develop, Test, and Implement Treatment Personalization Methods in Routine Practice

The route for the development, evaluation and dissemination of personalized psychological therapies is complex and challenging. In particular, the large sample sizes needed to provide adequately powered trials of newly-developed personalization approaches means that the traditional treatment development route is extremely inefficient. This paper outlines the promise of adaptive platform trials (APT) embedded within routine practice as a method to streamline development and testing of personalized psychological therapies, and close the gap to implementation in real-world settings. It focuses in particular on a recently-developed simplified APT design, the 'leapfrog' trial, illustrating via simulation how such a trial may proceed and the advantages it can bring, for example in terms of reduced sample sizes. Finally it discusses models of how such trials could be implemented in routine practice, including potential challenges and caveats, alongside a longer-term perspective on the development of personalized psychological treatments.

Development and validation of the Symptomatic Transdiagnostic Test (S2T)

INTRODUCTION

The categorical approach in psychiatry has received many criticisms. Modern research tends to develop a transdiagnostic approach. However, transdiagnostic works lack an overall understanding and focus mainly on anxiety and depression. The aim of the present study was to develop an easy to use tool to evaluate multiple dimensions opening the way for further research in the transdiagnostic approach. This will allow researchers to quickly assess the efficacy of psychotherapeutic interventions on multiple psychopathological dimensions.

METHOD

First, we identified the main symptoms of psychopathology in a sample of mental healthcare workers. Second, we developed the Symptomatic Transdiagnostic Test (S2T) to assess the main symptoms of psychopathology. Third, we evaluated its psychometric properties (exploratory and confirmatory factor analysis, internal consistency) in three non-clinical samples and one clinical sample.

RESULTS

The 66-item S2T included eleven factors referring to: i) negative thoughts and mood; ii) psycho-traumatic and maladaptive symptoms; iii) addiction symptoms; iv) disturbed eating behavior; v) disturbed perception and behavior; vi) panic and agoraphobia; vii) emotional lability; viii) dejection; ix) neurodevelopmental manifestations; x) anxiety and xi) psychic hyperactivity. We found a high internal consistency for the general scale (α=0.96) and the subscales. We found a good concurrent validity. As expected, we found higher levels of symptoms within the clinical population as compared to the non-clinical samples, except for addiction symptoms and disrupted eating behavior. We found negative associations between the symptomatic dimensions and psychological skills.

CONCLUSION

The S2T is a relevant tool for clinicians and researchers to assess the psychopathological profile. The main psychopathological symptoms are negatively related to the psychological skills.

The promise of compassion-based therapy as a novel intervention for adolescent PTSD

In this review, we summarize current evidence for compassion-based approaches for PTSD and the potential for their application to the adolescent PTSD population. Exposure to traumatic events is common in adolescence and PTSD remains a public health crisis. Accessibility, willingness, and engagement are significant barriers to established treatments for PTSD, with attrition rates as high as 50 %. Compassion-based therapies provide potential solutions to treatment obstacles by providing a non-threatening, transdiagnostic option unburdened by aspects of current trauma treatment which may be associated with treatment resistance (e.g., exposure, trauma narrative, induction of fear). Compassion-based approaches are intuitive for trauma treatment, as compassion activates the self-soothing system, thereby disarming the fear system and promoting affect regulation. Compassion-based treatments demonstrate reductions across a substantial range of PTSD symptoms in adults, however, in adolescents extant literature is sparse, with cross-sectional studies suggesting self-compassion is inversely associated with trauma-related psychopathology. Understanding the impact of compassion-based approaches on adolescent PTSD is warranted as the adolescent developmental period may be a particularly opportune time for this approach. Evaluation of the impact of compassion-based treatment on adolescent PTSD in clinical populations via randomized-controlled studies and comparison of its relative efficacy to current evidence-based practices is warranted.

Developing a Theory of Change for a Digital Youth Mental Health Service (Moderated Online Social Therapy): Mixed Methods Knowledge Synthesis Study

BACKGROUND

Common challenges in the youth mental health system include low access, poor uptake, poor adherence, and limited overall effectiveness. Digital technologies offer promise, yet challenges in real-world integration and uptake persist. Moderated Online Social Therapy (MOST) aims to overcome these problems by integrating a comprehensive digital platform into existing youth mental health services. Theory of change (ToC) frameworks can help articulate how and why complex interventions work and what conditions are required for success.

OBJECTIVE

The objective of this study is to create a ToC for MOST to explain how it works, why it works, who benefits and how, and what conditions are required for its success.

METHODS

We used a multimethod approach to construct a ToC for MOST. The synthesis aimed to assess the real-world impact of MOST, a digital platform designed to enhance face-to-face youth mental health services, and to guide its iterative refinement. Data were gathered from 2 completed and 4 ongoing randomized controlled trials, 11 pilot studies, and over 1000 co-design sessions using MOST. Additionally, published qualitative findings from diverse clinical contexts and a review of related digital mental health literature were included. The study culminated in an updated ToC framework informed by expert feedback. The final ToC was produced in both narrative and table form and captured components common in program logic and ToC frameworks.

RESULTS

The MOST ToC captured several assumptions about digital mental health adoption, including factors such as the readiness of young people and service providers to embrace digital platforms. External considerations included high service demand and a potential lack of infrastructure to support integration. Young people and service providers face several challenges and pain points MOST seeks to address, such as limited accessibility, high demand, poor engagement, and a lack of personalized support. Self-determination theory, transdiagnostic psychological treatment approaches, and evidence-based implementation theories and their associated mechanisms are drawn upon to frame the intervention components that make up the platform. Platform usage data are captured and linked to short-, medium-, and long-term intended outcomes, such as reductions in mental health symptoms, improvements in functioning and quality of life, reductions in hospital visits, and reduced overall mental health care costs.

CONCLUSIONS

The MOST ToC serves as a strategic framework for refining MOST over time. The creation of the ToC helped guide the development of therapeutic content personalization, user engagement enhancement, and clinician adoption through specialized implementation frameworks. While powerful, the ToC approach has its limitations, such as a lack of standardized methodology and the amount of resourcing required for its development. Nonetheless, it provides an invaluable roadmap for iterative development, evaluation, and scaling of MOST and offers a replicable model for other digital health interventions aiming for targeted, evidence-based impact.

Who benefits from guided internet-based interventions? A systematic review of predictors and moderators of treatment outcome

To our knowledge, no systematic review has been conducted on predictors or moderators of treatment outcome across diagnoses in guided internet-based interventions (IBIs) for adults. To identify who benefits from this specific format and therein inform future research on improving patient-treatment fit, we aimed to aggregate results of relevant studies. 2100 articles, identified by searching the databases PsycInfo, Ovid Medline, and Pubmed and through snowballing, were screened in April/May 2021 and October 2022. Risk of bias and intra- and interrater reliability were assessed. Variables were grouped by predictor category, then synthesized using vote counting based on direction of effect. N = 60 articles were included in the review. Grouping resulted in 88 predictors/moderators, of which adherence, baseline symptoms, education, age, and gender were most frequently assessed. Better adherence, treatment credibility, and working alliance emerged as conclusive predictors/moderators for better outcome, whereas higher baseline scores predicted more reliable change but higher post-treatment symptoms. Results of all other predictors/moderators were inconclusive or lacked data. Our review highlights that it is currently difficult to predict, across diagnoses, who will benefit from guided IBIs. Further rigorous research is needed to identify predictors and moderators based on a sufficient number of studies. PROSPERO registration: CRD42021242305.

The nature and neurobiology of fear and anxiety: State of the science and opportunities for accelerating discovery

Fear and anxiety play a central role in mammalian life, and there is considerable interest in clarifying their nature, identifying their biological underpinnings, and determining their consequences for health and disease. Here we provide a roundtable discussion on the nature and biological bases of fear- and anxiety-related states, traits, and disorders. The discussants include scientists familiar with a wide variety of populations and a broad spectrum of techniques. The goal of the roundtable was to take stock of the state of the science and provide a roadmap to the next generation of fear and anxiety research. Much of the discussion centered on the key challenges facing the field, the most fruitful avenues for future research, and emerging opportunities for accelerating discovery, with implications for scientists, funders, and other stakeholders. Understanding fear and anxiety is a matter of practical importance. Anxiety disorders are a leading burden on public health and existing treatments are far from curative, underscoring the urgency of developing a deeper understanding of the factors governing threat-related emotions.

An interdisciplinary multimodal integrative healthcare program for depressive and anxiety disorders

Objective

Although multimodal interventions are recommended in patients with severe depressive and/or anxiety disorders, available evidence is scarce. Therefore, the current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, for patients with (comorbid) depressive and/or anxiety disorders.

Methods

Participants were 3,900 patients diagnosed with a depressive and/or anxiety disorder. The primary outcome was Health-Related Quality of Life (HRQoL) measured with the Research and Development-36 (RAND-36). Secondary outcomes included: (1) current psychological and physical symptoms measured with the Brief Symptom Inventory (BSI) and (2) symptoms of depression, anxiety, and stress measured with the Depression Anxiety Stress Scale (DASS). The healthcare program consisted of two active treatment phases: main 20-week program and a subsequent continuation-phase intervention (i.e., 12-month relapse prevention program). Mixed linear models were used to examine the effects of the healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of 12-month relapse prevention program (T3).

Results

Results showed significant improvements from T0 to T2 for the primary variable (i.e., RAND-36) and secondary variables (i.e., BSI/DASS). During the 12-month relapse prevention program, further significant improvements were mainly observed for secondary variables (i.e., BSI/DASS) and to a lesser extent for the primary variable (i.e., RAND-36). At the end of the relapse prevention program (i.e., T3), 63% of patients achieved remission of depressive symptoms (i.e., DASS depression score ≤ 9) and 67% of patients achieved remission of anxiety symptoms (i.e., DASS anxiety score ≤ 7).

Conclusion

An interdisciplinary multimodal integrative healthcare program, delivered within a transdiagnostic framework, seems effective for patients suffering from depressive and/or anxiety disorders with regard to HRQoL and symptoms of psychopathology. As reimbursement and funding for interdisciplinary multimodal interventions in this patient group has been under pressure in recent years, this study could add important evidence by reporting on routinely collected outcome data from a large patient group. Future studies should further investigate the long-term stability of treatment outcomes after interdisciplinary multimodal interventions for patients suffering from depressive and/or anxiety disorders.

Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Background

Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods

To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results

Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion

MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

Self-knowledge as self-improvement in Plato’s dialogues and cognitive behavioural therapy

Some researchers who examine the similarities between philosophy and psychology conclude that engaging in philosophy can improve one’s mental health, instead of, or in addition to, traditional forms of therapy. This article reinforces this by establishing the relationship between self-knowledge as self-improvement in Plato’s dialogues and in cognitive behavioural therapy (CBT). Despite multiple important points of congruence, some authors have rejected the idea that self-knowledge in Plato can be assimilated to self-knowledge in psychotherapy. Here, I argue against this criticism by focusing on three key areas of interest: (a) self-knowledge as improving one’s beliefs via objective (nonsubjective) means, (b) self-knowledge as resulting in objective (nonsubjective) outcomes, and (c) self-knowledge as progress towards the Good. I reinforce the link by demonstrating that CBT uses methods which are equally objective as those of the Platonic dialogues. I then continue by claiming that the outcome of self-knowledge in both is also equally objective. Finally, I explore the nature of their relationship. Instead of arguing that self-knowledge in CBT is a modern version of Platonic self-knowledge, I propose that although not intended to, it functions as a preparatory process for one to be able to participate in Platonic self-knowledge.

How Effective Altruism Can Help Psychologists Maximize Their Impact

Although many psychologists are interested in making the world a better place through their work, they are often unable to have the impact that they would like. Here, we suggest that both individuals and psychology as a field can better improve human welfare by incorporating ideas from effective altruism, a growing movement whose members aim to do the most good by using science and reason to inform their efforts. In this article, we first briefly introduce effective altruism and review important principles that can be applied to how psychologists approach their work, such as the importance, tractability, and neglectedness framework. We then review how effective altruism can inform individual psychologists' choices. Finally, we close with a discussion of ideas for how psychology, as a field, can increase its positive impact. By applying insights from effective altruism to psychological science, we aim to integrate a new theoretical framework into psychological science, stimulate new areas of research, start a discussion on how psychology can maximize its impact, and inspire the psychology community to do the most good.

Adaptation, personalization and capacity in mental health treatments: a balancing act?

PURPOSE OF REVIEW

There are increasing calls for mental health treatments to be adapted for different groups to maximize their acceptability and benefit to patients. However, adaptations can be costly to develop and evaluate, difficult to implement in routine clinical practice and may reduce service capacity at a time when there is unprecedented unmet need. An alternative method is personalization on an individual level. This review provides an overview of the issues related to personalization and adaptation of mental health interventions.

RECENT FINDINGS

Several terms have been used to describe changes to existing therapies, these reflect different extents to which existing treatments have been changed. Evidence-based practice and modular therapies allow a level of flexibility within intervention delivery without formal changes and not all changes to therapy should be considered as a new/adapted treatment but instead regarded as 'metacompetence'. Implementing existing interventions in new contexts is preferable to developing new interventions in many instances. New guidance outlines how researchers can adapt and transfer interventions to varied contexts.

SUMMARY

The review provides proposed definitions of different changes to therapy. Modified and personalized treatments may improve acceptability to patients whilst maximizing implementation of evidence-based practice within clinical services.

What Should Be Considered When Assessing Hyperacusis? A Qualitative Analysis of Problems Reported by Hyperacusis Patients

Hyperacusis (decreased sound tolerance) is a prevalent complaint. Yet, to date, no research has qualitatively evaluated the types of problems experienced by adults with hyperacusis. Our service evaluation aims to determine the hyperacusis-related problem domains reported by patients and the degree to which these domains were reported together. Retrospective analysis was conducted on an anonymised clinical dataset from 306 patients who attended a UK tinnitus and hyperacusis treatment centre between 1994 and 2017. Conventional content analysis was used to categorise responses to the question 'Why is hyperacusis a problem?' into domains which were then subjected to a cluster analysis. Twenty-five problem domains were identified, of which 12 were further classified into three overarching categories. 'Fear', 'Reduced quality of life' and 'Physical reaction to sound' were most frequently reported problems. Cluster analysis revealed that 'Sleep difficulties' and 'Despondency', were commonly reported together. Adults with hyperacusis face many challenges in their everyday lives. The nature of these problems indicates the need to develop complex interventions and assessments to aid management of hyperacusis. Current hyperacusis questionnaires may be useful in identifying some problem domains, but further assessment thorough patient interviews is required to fully explore all potential problems and make informed decisions about treatment.

Two sides of the same coin? Patient and therapist experiences with a transdiagnostic blended intervention focusing on emotion regulation

INTRODUCTION

The combination of internet-based intervention and psychotherapy, commonly termed blended therapy (BT), has gained popularity in recent years. While advantages and disadvantages of BT have been identified from the patient and therapist perspective, the two perspectives have rarely been examined within the same treatment. Moreover, almost all available research on patient and therapist experiences with BT is disorder-specific. This study aimed to investigate patient and therapist experiences within the same transdiagnostic BT.

METHODS

A qualitative analysis of semi-structured interviews with eight patients and eight therapists taking part in a transdiagnostic blended intervention focusing on the topic of emotion regulation was conducted. A qualitative content analysis approach was used. Category frequencies were calculated and similarities and differences between the patient and therapist experience were explored.

RESULTS

Ten main themes and 59 subthemes were identified in the category system for patient interviews and ten main themes and 50 subthemes were identified in the category system for therapist interviews. Similarities and differences between the two perspectives were reported with regard to 1) expectations toward the intervention, 2) the internet-based intervention, 3) symptomatology and emotion regulation, 4) the therapeutic relationship and 5) the blended format.

CONCLUSION

This study provides first insights on the experiences with transdiagnostic BT focusing on emotion regulation. Based on the results, different recommendations for the improvement of transdiagnostic BT are made. Future research on patient and therapist experiences with transdiagnostic BT is necessary, in order to further improve the experience of those involved.

Promoting University Students' Mental Health through an Online Multicomponent Intervention during the COVID-19 Pandemic

The mental health of university students is a serious public health issue. The alarming trend of high levels of untreated psychological distress observed during the COVID-19 pandemic highlights the need for prevention programs. Digital tools are a promising means of delivering such programs. Web-based programs are acceptable and effective at improving mental health problems and general mental well-being. However, the usefulness of such digital prevention approaches to address the multiple issues raised by the COVID-19 pandemic needs to be tested. The current study assessed the effectiveness of an 8-week online intervention, integrating a variety of evidence-based strategies for improving French university students' mental health. Students were assigned to: (1) the online self-help program ETUCARE (n = 53), or (2) the control condition (n = 50). All the participants completed pre- and post-intervention questionnaires that assessed mental health problems and psychological well-being. The findings revealed that, compared to the control group, participation in the online program was associated with higher levels of psychological well-being post-test and fewer clinical symptoms of psychological distress, anxiety, and alcohol consumption. These preliminary findings suggest that the ETUCARE program is a promising multicomponent intervention to buffer the mental health consequences of the COVID-19 pandemic in French university students.

An Evidence-Based Theory of Psychological Adjustment to Long-Term Physical Health Conditions: Applications in Clinical Practice

OBJECTIVE

Around 30% of people with long-term physical health conditions (LTCs) experience comorbid anxiety and depression. For many, comorbid distress is linked to difficulties adjusting to the challenges of the LTC. The aims of this article are to present a transdiagnostic theoretical model of adjustment to LTCs (TMA-LTC), demonstrate the application of this model in clinical practice, and highlight the distinguishing features of treating LTC-related distress compared with treating primary anxiety and/or depression.

METHODS

A systematic review (k = 21) was conducted to collate preexisting evidence-based models of adjustment across LTCs. Models of adjustment for a range of LTCs were extracted and synthesized into a new preliminary TMA-LTC. Two expert consensus meetings were held, where experts rated the relevance and importance of all concepts within the models.

RESULTS

The TMA-LTC proposes that acute critical events or ongoing illness stressors can disrupt emotional equilibrium, and that whether a person returns to equilibrium and achieves good psychological adjustment depends on a number of cognitive and behavioral factors, as well as their interpersonal, intrapersonal, environmental, and illness-specific contexts. A case study is presented to demonstrate the clinical application of this model in treating illness-related distress, highlighting how it overcomes roadblocks that may be encountered when working primarily within traditional mental health paradigms.

CONCLUSIONS

As an empirically and clinically informed model, TMA-LTC provides a useful guide for assessment, formulation, and treatment in the context of psychological adjustment to LTCs. Future studies are needed to test treatments that have been developed based on TMA-LTC.

The association between repetitive negative thinking and distress across mental disorders: Preliminary findings from an outpatient treatment-seeking sample

Distress is a characteristic of various mental disorders. The transdiagnostic construct repetitive negative thinking (RNT) has been suggested to contribute to distress. However, there is little evidence that this association can actually be found across diagnostic categories. We analyzed this association for phobias, other anxiety disorders, stress disorders, depressive disorders and substance use disorders in 194 treatment-seeking individuals. RNT was associated with distress across all diagnostic categories with high effect sizes. Except for phobias, these associations were not attributable to general emotion regulation abilities. RNT might contribute to distress in several mental disorders which underlines its potential for transdiagnostic interventions.

Reactive and Regulative Temperament in Relation to Clinical Symptomatology and Personality Disorders in Patients with a Substance Use Disorder

Temperament and personality traits are important factors underlying the vulnerability for both the initiation and continuation of addictive behaviors. We investigated the influence of reactive and regulative temperament and their interaction in relation to clinical symptomatology and personality disorders (PDs) in a sample of 841 inpatients (68.1% males) with a substance use disorder (SUD). To assess reactive temperament we used the Behavioral Inhibition and Behavioral Activation Scales (BISBAS) and to assess regulative temperament we used the Effortful Control Scale. Clinical symptomatology and personality traits were measured by means of the Symptom Checklist-90 (SCL-90) and the Assessment of ADP-IV Personality Disorders (ADP-IV). Hierarchical regression analyses showed that both, clinical symptomatology and PDs were related to low levels of effortful control (EC). None of the two-way interactions (BIS × EC, BAS × EC) however were significantly related to psychopathology. Current findings highlight the role of effortful control (EC) in the expression of psychopathology in an adult sample of inpatients with SUD. Therapeutic interventions aiming at strengthening EC can possibly result in better treatment outcomes for both the addiction and the comorbid psychopathology.

Can We Boost Treatment Adherence to an Online Transdiagnostic Intervention by Adding Self-Enhancement Strategies? Results From a Randomized Controlled Non-inferiority Trial

Background: Internet-delivered psychotherapy represents an impactful large-scale solution for addressing psychological disorders. In spite of its flexibility and scalability, the fact that the ones in need have to initiate and sustain the curse of the treatment by themselves comes with considerable downsides in terms of treatment adherence. One solution could be to increase the ease of use and attractivity of the strategies and assignments from such programs. The present study aims to address this issue by incorporating a series of self-oriented strategies to the validated internet-delivered short version of the Unified Protocol (UP). By this mean we intend to complement the symptom-focused assignments, which may be more suitable in a therapist assisted context, with ones designed for self-enhancement, which may be easier approached as self-initiated. Based on a randomized controlled non-inferiority trial we compared the modified version of the UP with the standard short version. Method: The trial design was factorial, with two parallel arms and three measurement moments (baseline, post-intervention and 6-months follow-up). A total of 284 participants were randomly assigned to the intervention or the active control groups. The intervention group (baseline n = 142) received the self-enhanced nine modules of the UP (Self-enhanced 9UP) while the active control (baseline n = 142) received the standard nine modules (9UP). The newly added techniques were inspired by the acceptance and commitment therapy and were specific for self-concepts such as self-compassion or unconditional self-acceptance. Both programs lasted for 9 weeks. The non-inferiority of the Self-enhanced 9UP was tested against a margin of d = -0.35, on the following primary outcome measures: Patient Health Questionnaire 9 (PHQ9) - operationalization for depression; Generalized Anxiety Disorder 7 (GAD7) - operationalization for generalized anxiety or worry; Social Phobia Inventory (SPIN) - operationalization for social phobia; and Panic Disorder Severity Scale-Self Report (PDSS-SR) - that showed participants' level of panic. Treatment adherence was assessed through the drop-out analyses and the engagement in completing the homework assignments. Secondary outcome measures included several self-concept measures: Self-Compassion Scale (SCS); Rosenberg Self-Esteem Scale (RSES); Unconditional Self-Acceptance Questionnaire (USAQ); New General Self-Efficacy Scale (NGSE); and Self-Concept Clarity Scale (SCCS). On the secondary outcomes we explored the potential boost of effectiveness produced by the newly added self-enhancement components. Results: The dropout rates were similar in both groups (approximately 45%) and high overall. Adherence to treatment assignments was also modest and similar between groups (on average participants completed approximately half of the tasks), without a statistically significant bias toward the self-enhancement ones. Overall, both the intention-to-treat and completers analyses yielded no significant group by time interactions for any of the post-intervention and follow-up measurements, but a few non-inferiority analyses suggested that the Self-enhanced 9UP had a significantly weaker effectiveness than the standard 9UP. Within-group analyses showed significant alleviations on all the primary and secondary outcomes for both groups. The effect size estimates were mainly medium and high, and their magnitude tended to be kept also at 6-months follow-up. Discussion: We failed to increase treatment adherence, but we found support with some exceptions, for the non-inferiority hypothesis. Hence, the alterations performed to the 9UP protocol, although they did not boost the treatment attractiveness, they also did not decrease the treatment effectiveness as suggested by most non-inferiority analyses. Likewise, the gain on self-concepts was produced by both groups. Hence, the short version of the UP seems to have the potential of effectively alleviating a larger palette of psychological variables associated with mental health symptoms than previously known. Even though our main objective was only partially achieved, these secondary results are insightful and could open new avenues of research. Clinical Trial Registration: This trial has been registered at ClinicalTrials.Gov (NCT03917550; 17 April 2019; https://clinicaltrials.gov/ct2/show/NCT03917550).

Feasibility and clinical utility of a transdiagnostic Internet-delivered rational emotive and behavioral intervention for adolescents with anxiety and depressive disorders

BACKGROUND

Transdiagnostic interventions delivered for children and adolescents show promising results. In order to increase access to treatment, recent developments in technology have led to alternatives to face-to-face interventions. Transdiagnostic Internet-delivered interventions can be effective for adult anxiety and depressive disorders, but research is more limited regarding the efficacy of such treatments for young populations diagnosed with anxiety and or depressive disorders.

OBJECTIVE

This study aims to investigate the feasibility and clinical utility of a transdiagnostic Internet-delivered intervention based on Rational emotive behavior therapy for adolescents diagnosed with anxiety and depressive disorders.

METHODS

We tested the preliminary efficacy of a six-week intervention in an open trial, pre-post design.

RESULTS

Our results suggest that the intervention is feasible and can be included as a treatment for adolescents with anxiety and depressive disorders, being associated with moderate to large pre-post effect sizes on self-reported anxiety and depressive symptoms, as well as on negative patterns of thinking and knowledge acquisition. Satisfaction with the intervention was high.

CONCLUSIONS

Transdiagnostic Internet-delivered interventions for adolescents with anxiety and depressive symptoms are feasible. Future testing of the efficacy of such interventions in randomized controlled trials should be conducted.

Transdiagnostic Processes as Mediators of Change in an Internet-Delivered Intervention Based on the Unified Protocol

Background

Transdiagnostic treatments target shared mechanisms between disorders to facilitate change across diagnoses. The Unified Protocol (UP) aims at changing dysfunctional reactions towards emotions by increasing mindful emotion awareness and cognitive flexibility, as well as decreasing anxiety sensitivity and emotion avoidance.

Method

We investigated whether these transdiagnostic processes were malleable by treatment and mediated the relationship between treatment and outcome in an internet-delivered adaptation of the UP. N = 129 participants with mixed anxiety, depressive, and somatic symptom disorders were randomized to treatment or waitlist.

Results

The treatment yielded significant changes in all transdiagnostic processes over time in comparison to a waitlist condition. In separate mediator models, significant mediating effects were found for mindfulness, cognitive flexibility, behavioral activation, and experiential avoidance. When all mediators were combined in a multiple mediator model, the indirect effects through mindfulness and cognitive flexibility emerged as significant.

Conclusion

These findings add to the growing body of research on transdiagnostic processes as mediators of change and emphasize mindfulness and cognitive flexibility as a transdiagnostic treatment target. However, these results should be interpreted cautiously, as temporal precedence could not be established.

[All in the mix? Blended psychotherapy as an example of digitalization in psychotherapy]

Hintergrund

Über die letzten Jahrzehnte wurden verschiedene Ansätze zur Digitalisierung der Psychotherapie (PT) entwickelt. Eine Behandlungsform stellt die Kombination von „Face-to-face“-PT und Online-Interventionen, die „Blended-PT“, dar. Während das Forschungsinteresse zu Blended-PT in den letzten Jahren zugenommen hat, wurde die praktische Anwendung von Blended-PT im deutschsprachigen Raum bisher weniger stark umgesetzt. Auch bedingt durch die globale, durch die „coronavirus disease 2019“ (COVID-19) ausgelöste Pandemie gewinnen Blended-PT und andere Online-Ansätze zunehmend an Bedeutung.

Ziel der Arbeit

Ein Überblick zum Thema und zu verschiedenen Formen von Blended-PT wird gegeben. Im Weiteren wird auf die Wirksamkeit, die Sicht der Patient:innen und Therapeut:innen sowie auf das Thema der Implementierung eingegangen.

Material und Methoden

Narrative Übersicht der Literatur zum Thema Blended-PT; auf Basis einer umfassenden Suche werden wichtige Überlegungen und Befunde eingeordnet und beschrieben.

Ergebnisse

Der Begriff der Blended-PT wird bisher uneinheitlich verwendet. In Anlehnung an Blended-Learning-Ansätze können „blends“ auf verschiedenen Ebenen stattfinden. Es kann zwischen ergänzenden und transformierenden Blends unterschieden werden. In transformierenden Blends verändert das Format die Face-to-face-PT grundlegend. Zu einigen Blended-PT-Formen gibt es bereits Wirksamkeitsbelege, zu anderen besteht dringender Forschungsbedarf. Im Vergleich zu Face-to-face-PT und reiner Online-Therapie könnte die Blended-PT verschiedene Vorteile bieten.

Schlussfolgerung

Das Interesse an Blended-PT wächst aufseiten von Patient:innen und Therapeut:innen. Um evidenzbasierte Blended-PT erfolgreich anbieten zu können, bedarf es der engen Zusammenarbeit zwischen Wissenschaft, Institutionen, Therapeut:innen und Kostenträgern im Gesundheitssystem.

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.