Exploring the relation of depression and overt behavior with daily diaries

Heterogeneity in the trajectories of psychological distress among late adolescents during the COVID-19 pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has constrained opportunities in social, educational and professional domains, leading to developmental challenges for adolescents initiating their transition to adulthood. Meta-analysis indicated that there was a small increase in psychological distress during the first year of the COVID-19 pandemic. However, significant heterogeneity in the psychological response to the COVID-19 pandemic was noted. Developmental antecedents as well as social processes may account for such heterogeneity. The goal of this study was to characterize trajectories of psychological distress in late adolescence during the COVID-19 pandemic.

Methods

5014 late adolescents born between 2000 and 2002 from the UK Millennium Cohort Study completed online self-reported assessments at three occasions during the first year of the COVID-19 pandemic (May 2020, September/October 2020 and February/March 2021). These surveys assessed psychological distress, loneliness, social support, family conflict, as well as other pandemic stressors. Information on developmental antecedents were obtained when cohort members were 17 years of age.

Results

Four distinct trajectories class were identified. Normative class (52.13%) experienced low and decreasing levels of psychological distress, while moderately increasing class (31.84%) experienced a small, but significant increase in distress over time and increasing class (8.75%) exhibited a larger increase in distress after the first wave of the pandemic. Inverted U-shaped class (7.29%) experienced elevated psychological distress during the first wave of the pandemic, followed by a decrease in distress in subsequent waves of the pandemic. Larger longitudinal increases in loneliness were noted among individuals in the elevated distress trajectory, compared to other trajectories. Pre-pandemic psychopathology was associated with elevated distress early in the pandemic.

Conclusions

The largest trajectory showed low and declining psychological distress, highlighting the resilience of the majority of late adolescents. However, a subgroup of adolescents experienced large increases in psychological distress, identifying a group of individuals more vulnerable to pandemic-related stress.

All Goals are Equal: No Interactions Between Depressive Symptoms and Goal Characteristics on Goal Progress

Introduction. Depression is related to poor achievement and impacts people's capacity to attain their goals (American Psychiatric Association, 2013; Johnson et al., 2010; Street, 2002). But do depressive symptoms impact goal pursuit differently depending on the kinds of goals that people pursue? Methods. Across three studies (total N = 666 undergraduate students, total goals = 2,546), we examine the role of up to 16 goal characteristics as moderators in the relationship between depressive symptoms and goal progress. Depressive symptoms and goal characteristics were assessed at baseline, and participants reported on goal progress at a follow-up 1 month (Study 1), 4 months (Study 2), or 8 months (Study 3) later. Results. The effect of depressive symptoms on goal progress was nonsignificant in two out of three studies (including one with low power), but an internal meta-analysis presented a small negative effect. Most goal characteristics did not moderate the relationship between depressive symptoms and goal progress, with Bayes factors suggesting substantial to very strong evidence in favor of the null hypotheses. Discussion. The kinds of goals students pursue may not matter in the presence of depressive symptoms. On one hand, this may provide a bleak outlook in highlighting that depressive symptoms impact all goals regardless of how well they are selected. On the other hand, the effects were small, which may offer a hopeful outlook for undergraduate students experiencing depressive symptoms, who may still be able to progress on their personal goals.

Behavioral mediators of stress-related mood symptoms in adolescence & young adulthood

BACKGROUND

Stress is a risk factor for unipolar and bipolar mood disorders, but the mechanisms linking stress to specific symptoms remain elusive. Behavioral responses to stress, such as impulsivity and social withdrawal, may mediate the associations between stress and particular mood symptoms.

METHODS

This study evaluated behavioral mediators of the relationship between self-reported intensity of daily stress and mood symptoms over up to eight weeks of daily diary surveys. The sample included individuals with unipolar or bipolar disorders, or with no psychiatric history (n = 113, ages 15-25).

RESULTS

Results showed that higher daily stress was related to higher severity of mania, and this pathway was mediated by impulsive behaviors. Higher stress also predicted higher severity of anhedonic depression, and social withdrawal mediated this relationship. A k-means clustering analysis revealed six subgroups with divergent profiles of stress-behavior-symptom pathways.

LIMITATIONS

Given the observational study design, analyses cannot determine causal relationships amongst these variables. Further work is needed to determine how relationships between these variables may vary based on stressor type, at different timescales, and within different populations.

CONCLUSIONS

Findings support a theoretical model in which impulsivity and social withdrawal act as behavioral mediators of the relationship between stress and mood symptoms. Additionally, distinct patterns of reactivity distinguished subgroups of people vulnerable to particular types of mood symptoms. These results provide novel information about how stress-reactive behaviors relate to specific mood symptoms, which may have clinical relevance as targets of intervention.

How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators

INTRODUCTION

Behavioural activation is an effective treatment for depression, but little is known about its working mechanisms. Theoretically, its effect is thought to rely on an interplay between activation and environmental reward.

OBJECTIVE

The present systematic review examines the mediators of behavioural activation for depression.

METHODS

A systematic literature search without time restrictions in Medline, EMBASE, PsycINFO, The Cochrane Library, and CINAHL resulted in 14 relevant controlled and uncontrolled prospective treatment studies that also performed formal mediation analyses to investigate their working mechanisms. After categorising the mediators investigated, we systematically compared the studies' methodological quality and performed a narrative synthesis of the findings.

RESULTS

Most studies focused on activation or environmental reward, with 21 different mediators being investigated using questionnaires that focused on psychological processes or beliefs. The evidence for both activation and environmental reward as mediators was weak.

CONCLUSIONS

Non-significant results, poor methodological quality of some of the studies, and differences in questionnaires employed precluded any firm conclusions as to the significance of any of the mediators. Future research should exploit knowledge from fundamental research, such as reward motivation from neurobiology. Furthermore, the use of experience sampling methods and idiographic analyses in bigger samples is recommended to investigate potential causal pathways in individual patients.

Neural Changes in Reward Processing Following Approach Avoidance Training for Depression

Altered approach motivation is hypothesized to be critical for the maintenance of depression. Computer-administered approach-avoidance training programs to increase approach action tendencies toward positive stimuli produce beneficial outcomes. However, there have been few studies examining neural changes following approach-avoidance training. Participants with Major Depressive Disorder were randomized to an Approach Avoidance Training (AAT) manipulation intended to increase approach tendencies for positive social cues (n=13) or a control procedure (n=15). We examined changes in neural activation (primary outcome) and connectivity patterns using Group Iterative Multiple Model Estimation during a social reward anticipation task (exploratory). A laboratory-based social affiliation task was also administered following the manipulation to measure affect during anticipation of real-world social activity. Individuals in the AAT group demonstrated increased activation in reward processing regions during social reward anticipation relative to the control group from pre to post-training. Following training, connectivity patterns across reward regions were observed in the full sample and connectivity between the medial PFC and caudate was associated with anticipatory positive affect before the social interaction; preliminary evidence of differential connectivity patterns between the two groups also emerged. Results support models whereby modifying approach-oriented behavioral tendencies with computerized training leads to alterations in reward circuitry. (NCT02330744).

Engaging in pleasant events explains the relation between physical disability and mental health outcomes in older adults

OBJECTIVES

This study expands the body of research examining mediators of the association between physical disability and mental health outcomes. Based on the behavioral model of depression, frequency of pleasant events were examined as a mediator between physical disability and mental health outcomes including depressive symptoms, meaning in life, and positive affect. We predicted that physical disability would have a significant indirect effect on mental health outcomes through the lower frequency of pleasant events.

METHODS

Cross-sectional study of 82 community-dwelling adults, M_age = 77.6, SD = 8.0, 64.6% female, was conducted. Self-report instruments measured frequency of pleasant events, physical disability, and mental health outcomes (depression symptoms, positive affect, and meaning in life).

RESULTS

Simple mediation analyses demonstrated a significant indirect effect of physical disability on depressive symptoms (unstandardized coefficient = 0.16, 95% bias-corrected CI 0.03, 0.41), positive affect (unstandardized coefficient = -2.65, 95% bias-corrected CI -5.38, -0.88), and meaning in life (unstandardized coefficient = -1.58, 95% bias-corrected CI -3.19, -0.47) through engagement in pleasant events.

CONCLUSION

Physical disability was associated with greater depressive symptoms and lower positive affect and meaning in life through reduced frequency of pleasant events. These findings are consistent with the behavioral model of depression and support several applied recommendations for reducing the burden of physical disability on mental health outcomes.

Mood and Activity Measured Using Smartphones in Unipolar Depressive Disorder

Background: Smartphones comprise a promising tool for symptom monitoring in patients with unipolar depressive disorder (UD) collected as either patient-reportings or possibly as automatically generated smartphone data. However, only limited research has been conducted in clinical populations. We investigated the association between smartphone-collected monitoring data and validated psychiatric ratings and questionnaires in a well-characterized clinical sample of patients diagnosed with UD. Methods: Smartphone data, clinical ratings, and questionnaires from patients with UD were collected 6 months following discharge from psychiatric hospitalization as part of a randomized controlled study. Smartphone data were collected daily, and clinical ratings (i.e., Hamilton Depression Rating Scale 17-item) were conducted three times during the study. We investigated associations between (1) smartphone-based patient-reported mood and activity and clinical ratings and questionnaires; (2) automatically generated smartphone data resembling physical activity, social activity, and phone usage and clinical ratings; and (3) automatically generated smartphone data and same-day smartphone-based patient-reported mood and activity. Results: A total of 74 patients provided 11,368 days of smartphone data, 196 ratings, and 147 questionnaires. We found that: (1) patient-reported mood and activity were associated with clinical ratings and questionnaires (p < 0.001), so that higher symptom scores were associated with lower patient-reported mood and activity, (2) Out of 30 investigated associations on automatically generated data and clinical ratings of depression, only four showed statistical significance. Further, lower psychosocial functioning was associated with fewer daily steps (p = 0.036) and increased number of incoming (p = 0.032), outgoing (p = 0.015) and missed calls (p = 0.007), and longer phone calls (p = 0.012); (3) Out of 20 investigated associations between automatically generated data and daily patient-reported mood and activity, 12 showed statistical significance. For example, lower patient-reported activity was associated with fewer daily steps, shorter distance traveled, increased incoming and missed calls, and increased screen-time. Conclusion: Smartphone-based self-monitoring is feasible and associated with clinical ratings in UD. Some automatically generated data on behavior may reflect clinical features and psychosocial functioning, but these should be more clearly identified in future studies, potentially combining patient-reported and smartphone-generated data.

Psychosocial factors associated with treatment outcomes in women with obesity and major depressive disorder who received behavioral activation for depression

Behavioral activation is an empirically supported treatment for depression, but much is unknown about factors associated with treatment response. The present study aimed to determine whether baseline levels and subsequent changes in psychosocial factors were associated with improvement in depression in women with comorbid obesity who received behavioral activation treatment for depression and a lifestyle intervention. Multilevel modeling was used to estimate the associations between psychosocial factors and change in depression scores during the first 10 weeks of treatment and associations between changes in psychosocial factors from baseline to 6-month follow-up and change in depression over the same time period. No baseline psychosocial factors were associated with depression improvement during treatment (p = 0.110-0.613). However, greater improvement in hedonic capacity (p = 0.001), environmental reward (p = 0.004), and social impairment (p = 0.012) were associated with greater reductions in depression over 6 months. Findings highlight the differential relationship specific psychosocial factors have with depression treatment outcomes.

Commitment is Not Enough: A Longitudinal Investigation of Goal Commitment, Confidence, and Depressive Symptoms in Personal Goal Pursuit

Introduction: Symptoms of depression are associated with difficulty achieving personal goals. Empirical investigations suggest that depressed individuals do not differ from healthy controls in their commitment to personal goals (i.e., goal commitment), though they express less confidence in their abilities to achieve goals (i.e., goal-related confidence). Despite the relevance of motivational constructs, including goal commitment and confidence, to both depression and goal striving, there is a dearth of research examining these variables as they relate to depressive symptoms and goal progress across time.

Method: To address this gap, we tracked the goal pursuits of 139 undergraduate participants oversampled for elevated symptoms of depression at a large, Midwestern university at three time-points. Participants completed a baseline assessment that included The Center for Epidemiologic Studies—Depression Scale (CES-D; Radloff, 1977) and a free-response goal-setting activity. They were asked to report goal progress and re-rate commitment and confidence for any not-yet-attained goals 2 weeks later and, finally, to report on goal attainment at a 2-month follow-up.

Results: As predicted, the association between depressive symptoms and concurrently-reported goal commitment was not significant. However, less goal progress and early decreases in goal commitment and confidence reported at 2-week follow-up acted as indirect paths through which baseline depressive symptoms predicted poor longer-term goal outcomes.

Discussion: Future investigators could experimentally test the associations between these variables to better understand the ways in which manipulating one aspect of goal striving might causally influence the others.

Independent and relative effects of stress, depressive symptoms, and affect on college students' daily health behaviors

Stress and depressive symptoms are associated with maladaptive health behavior practices such as unhealthy eating, sedentary behavior, insufficient sleep, and substance use. The relative and interactive effects of stress and depressive symptoms on health behavior practices are less well understood. The present study examined these processes in a daily diary study of 127 college students. Results from hierarchical generalized linear models indicated that depressive symptoms, and chronic and daily stress, but not acute stressful life events, were significantly associated with a composite score of daily maladaptive health behavior engagement (depressive symptoms b = .01, SE= .00, p < .01; chronic stress, b = .03, SE= .01, p < .01; daily stress, b = .01, SE= .01, p = .02); unexpectedly, the effect of stress on health behaviors was not moderated by depressive symptoms. Additionally, results demonstrated that the effect of depressive symptoms on health behaviors was mediated by fluctuations in daily negative affect. These results bear implications for intervention during a crucial period in the development of mental and physical health.

Movement patterns in women at risk for perinatal depression: use of a mood-monitoring mobile application in pregnancy

Objectives

To examine, using a smartphone application, whether mood is related to daily movement patterns in pregnant women at risk for perinatal depression.

Materials and Methods

Thirty-six women with elevated depression symptoms (PHQ-9 ≥ 5) in pregnancy used the application for 8 weeks. Mood was reported using application-administered surveys daily (2 questions) and weekly (PHQ-9 and GAD-7). The application measured daily mobility (distance travelled on foot) and travel radius. Generalized linear mixed-effects regression models estimated the association between mood and movement.

Results

Women with milder depression symptoms had a larger daily radius of travel (2.7 miles) than women with more severe symptoms (1.9 miles), P  = .04. There was no difference in mobility. A worsening of mood from the prior day was associated with a contracted radius of travel, as was being in the group with more severe symptoms. No significant relationships were found between anxiety and either mobility or radius.

Discussion

We found that the association of mood with radius of travel was more pronounced than its association with mobility. Our study also demonstrated that a change in mood from the prior day was significantly associated with radius but not mood on the same day that mobility and radius were measured.

Conclusion

This study lays the groundwork for future research on how smartphone mood-monitoring applications can combine actively and passively collected data to better understand the relationship between the symptoms of perinatal depression and physical activity that could lead to improved monitoring and novel interventions.

Reward and punishment learning in daily life: A replication study

Day-to-day experiences are accompanied by feelings of Positive Affect (PA) and Negative Affect (NA). Implicitly, without conscious processing, individuals learn about the reward and punishment value of each context and activity. These associative learning processes, in turn, affect the probability that individuals will re-engage in such activities or seek out that context. So far, implicit learning processes are almost exclusively investigated in controlled laboratory settings and not in daily life. Here we aimed to replicate the first study that investigated implicit learning processes in real life, by means of the Experience Sampling Method (ESM). That is, using an experience-sampling study with 90 time points (three measurements over 30 days), we prospectively measured time spent in social company and amount of physical activity as well as PA and NA in the daily lives of 18-24-year-old young adults (n = 69 with anhedonia, n = 69 without anhedonia). Multilevel analyses showed a punishment learning effect with regard to time spent in company of friends, but not a reward learning effect. Neither reward nor punishment learning effects were found with regard to physical activity. Our study shows promising results for future research on implicit learning processes in daily life, with the proviso of careful consideration of the timescale used. Short-term retrospective ESM design with beeps approximately six hours apart may suffer from mismatch noise that hampers accurate detection of associative learning effects over time.

Self-esteem in Early Adolescence as Predictor of Depressive Symptoms in Late Adolescence and Early Adulthood: The Mediating Role of Motivational and Social Factors

Ample research has shown that low self-esteem increases the risk to develop depressive symptoms during adolescence. However, the mechanism underlying this association remains largely unknown, as well as how long adolescents with low self-esteem remain vulnerable to developing depressive symptoms. Insight into this mechanism may not only result in a better theoretical understanding but also provide directions for possible interventions. To address these gaps in knowledge, we investigated whether self-esteem in early adolescence predicted depressive symptoms in late adolescence and early adulthood. Moreover, we investigated a cascading mediational model, in which we focused on factors that are inherently related to self-esteem and the adolescent developmental period: approach and avoidance motivation and the social factors social contact, social problems, and social support. We used data from four waves of the TRAILS study (N = 2228, 51% girls): early adolescence (mean age 11 years), middle adolescence (mean age 14 years), late adolescence (mean age 16 years), and early adulthood (mean age 22 years). Path-analyses showed that low self-esteem is an enduring vulnerability for developing depressive symptoms. Self-esteem in early adolescence predicted depressive symptoms in late adolescence as well as early adulthood. This association was independently mediated by avoidance motivation and social problems, but not by approach motivation. The effect sizes were relatively small, indicating that having low self-esteem is a vulnerability factor, but does not necessarily predispose adolescents to developing depressive symptoms on their way to adulthood. Our study contributes to the understanding of the mechanisms underlying the association between self-esteem and depressive symptoms, and has identified avoidance motivation and social problems as possible targets for intervention.

Sexual Assault Severity and Depressive Symptoms as Longitudinal Predictors of the Quality of Women's Sexual Experiences

Depressive symptoms are one consequence of adult/adolescent sexual victimization (ASV) and are linked to sexual health. Female nonproblem drinkers (N = 419) with an ASV history participated in a one-year longitudinal study. Participants completed measures of lifetime ASV severity and four quarterly assessments of depressive symptoms, ASV severity, and sexual experience quality. Multilevel models revealed that depressive symptoms interacted with ASV severity: Women with low-lifetime ASV severity reported higher ratings of sexual pain as depressive symptoms increased. ASV reported during assessment months predicted sexual experience quality. Interventions to improve survivors' sexual experiences should consider incorporating treatment for depressive symptoms.

Depressive Symptoms and the Anticipation and Experience of Uplifting Events in Everyday Life

OBJECTIVE

Despite proliferation of laboratory-based studies examining reward functioning in depression, few studies have examined these processes in everyday life. We addressed this shortcoming by exploring experience and anticipation of uplifting experiences under ecologically valid conditions METHOD: One hundred fifty-seven young adults, oversampled for depressive symptoms, completed a 14-day diary tracking mood in relation to recent and anticipated positive events RESULTS: Consistent with studies supporting "mood-brightening" effects in depression, participants with greater baseline dysphoria showed stronger associations between elevated daily uplifts and lower daily depressive symptoms, particularly when events were interpersonal in nature. Baseline dysphoria was associated with lower daily anticipation of positive next-day experiences; however, when dysphoric individuals did anticipate positive experiences, they experienced greater reductions in depressed mood CONCLUSION: Results suggest that despite reward processing deficits found in laboratory studies, dysphoric individuals show improvements in mood in conjunction with anticipation and consumption of uplifting events in daily life.

Effects of Engaging in Repeated Mental Imagery of Future Positive Events on Behavioural Activation in Individuals with Major Depressive Disorder

Depression is associated with decreased engagement in behavioural activities. A wide range of activities can be promoted by simulating them via mental imagery. Mental imagery of positive events could thus provide a route to increasing adaptive behaviour in depression. The current study tested whether repeated engagement in positive mental imagery led to increases in behavioural activation in participants with depression, using data from a randomized controlled trial (Blackwell et al. in Clin Psychol Sci 3(1):91–111, 2015. doi:10.1177/2167702614560746). Participants (N = 150) were randomized to a 4-week positive imagery intervention or an active non-imagery control condition, completed via the internet. Behavioural activation was assessed five times up to 6 months follow-up using the Behavioural Activation for Depression Scale (BADS). While BADS scores increased over time in both groups, there was an initial greater increase in the imagery condition. Investigating mental imagery simulation of positive activities as a means to promote behavioural activation in depression could provide a fruitful line of enquiry for future research.

Behavioral activation for depression in older adults: theoretical and practical considerations

Late-life depression (LLD) is a major public health concern that can have devastating effects on older individuals and their families. Behavioral theories predict that decreases in response-contingent positive reinforcement and increases in negatively reinforced avoidance behaviors, often accompanied by aversive life events, result in the selection and maintenance of depression. Based on these theories, behavioral activation treatments for depression are designed to facilitate structured increases in enjoyable activities that increase opportunities for contact with positive reinforcement. We discuss the applicability of behavioral models for LLD, and we briefly review current behavioral activation interventions for LLD with an emphasis on implications for future behavior-analytic research. Behavioral activation has been demonstrated to be effective in reducing depression and increasing healthy behavior in older adults. Potential challenges and considerations for future research are discussed. We suggest that applied behavior analysts and clinical behavior analysts are particularly well suited to improve and expand on the knowledge base and practical application of behavioral activation interventions with this population.

Depressive symptoms, lifestyle structure, and ART adherence among HIV-infected individuals: a longitudinal mediation analysis

Despite the well-documented relationship between depression and antiretroviral therapy (ART) nonadherence, few studies have identified explanatory pathways through which depression affects adherence. The current study tested lifestyle structure-the degree of organization and routinization of daily activities-as a mediator of this relationship, given previous evidence of lifestyle structure being associated with both depression and ART nonadherence. HIV-infected individuals starting or re-starting ART in the California Collaborative Treatment Group 578 study (n = 199) were assessed over 48 weeks. Adherence was measured using electronic monitoring caps to determine dose timing and doses taken, and viral load was assessed. The mediating role of lifestyle structure was tested using generalized linear mixed-effects modeling and bootstrapping. Lifestyle significantly mediated the relationship between depression and both measures of ART adherence behavior. Interventions that minimize disruptions to lifestyle structure and link adherence to daily activities may be useful for individuals with depression and ART nonadherence.

Analog study investigating diary assessments of rewards and punishments for emotional states

Behavioral Activation is a treatment for depression relying on rewards from activities; but it is possible that the effects of punishments should also be considered, as should its generalizability to the healthy population. Effect of rewards and punishments on emotional states and depression were investigated by using the daily diary method. Participants (7 men, 21 women; M age = 19.4 yr.) recorded their daily activities and the intensity of rewards and punishments accompanying each activity for one week. Positive and negative affects of participants were assessed using the Japanese version of the Positive Affect and Negative Affect Schedule. Multiple regression analysis indicated that both rewards and punishments predicted depressive symptoms. Moreover, rewards (but not punishments) predicted positive affect, whereas punishments predicted negative affects (and rewards did not). These preliminary results suggest that the effects of both rewards and punishments given for activities should be considered in models of behavioral activation.

Psychological interventions for coronary heart disease: cochrane systematic review and meta-analysis

BACKGROUND

Depression and anxiety are common in cardiac patients, and psychological interventions may also be used as part of general cardiac rehabilitation programs.

PURPOSE

This study aims to estimate effects of psychological interventions on mortality and psychological symptoms in this group, updating an existing Cochrane Review.

METHOD

Systematic review and meta-regression analyses of randomized trials evaluating a psychological treatment delivered by trained staff to patients with a diagnosed cardiac disease, with a follow-up of at least 6 months, were used.

RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularization, or non-fatal infarction. Psychological intervention did result in small/moderate improvements in depression and anxiety, and there was a small effect for cardiac mortality.

CONCLUSION

Psychological treatments appear effective in treating patients with psychological symptoms of coronary heart disease. Uncertainty remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Does Amount and Type of Activity Matter in Behavioral Activation? A Preliminary Investigation of the Relationship between Pleasant, Functional, and Social Activities and Outcome

BACKGROUND

Accumulating evidence supports behavioral activation (BA) as an effective stand-alone treatment for improving depression and related conditions, though little is known about the factors that influence positive outcomes. Such research is ripe for future dissemination and implementation efforts, particularly among vulnerable older adult populations in need of such efficacious and transportable treatments.

AIMS

Given the central but largely unexamined role that increasing activities plays in BA, we investigated the association between participation in weekly activities and treatment outcome.

METHOD

As a preliminary study of this research question, we report on a sample of 20 older adults with symptoms of depression and complicated bereavement who completed 5 weeks of BA, pre- and posttreatment measures, and weekly planners of BA activities. All activities were coded as either functional or pleasurable (by participants) and if they were social in nature (by trained coders).

RESULTS

Overall, BA was associated with reductions in symptomatology. However, participants' total number of reported activities, and their relative proportion of functional, pleasurable, and social activities, did not significantly relate to their improvement in symptoms.

CONCLUSION

One interpretation of the findings suggests that countering avoidance more generally, potentially independent of the specific type or total amount of activation activities, may be associated with amelioration of symptomatology.

Obsessive-compulsive disorder and comorbid depression: the role of OCD-related and non-specific factors

Although comorbid depression is a predictor of poor treatment response in obsessive-compulsive disorder (OCD), there is limited understanding of factors that contribute to depression severity in OCD. The current study examines the influence of OCD-related factors (autogenous obsessions and obsessional beliefs) and non-specific factors (avoidance and anxiety) on depression severity in a sample of OCD patients. There were 56 participants with only OCD and 46 with OCD and comorbid depression. Self-report questionnaires measuring depression, OCD-related factors, and non-specific factors were completed. Although there were no significant differences between the two groups on these variables, depression severity was positively correlated with anxiety, avoidance, obsessional beliefs, and autogenous obsessions in the whole sample. When entered into a multiple regression model to predict depression severity, these factors accounted for 51% of the variance. While OCD-related factors remained significant predictors after controlling for non-specific factors, the non-specific factors made the most significant contributions to the model. Our findings suggest that in addition to dealing with autogenous obsessions, addressing anxiety and avoidance might lead to improvements in the treatment of OCD with comorbid depression.

Gender Differences in Depression: Assessing Mediational Effects of Overt Behaviors and Environmental Reward through Daily Diary Monitoring

Gender differences in the prevalence of depression are well documented. To further explore the relation between gender and depression, this study used daily diaries to examine gender differences within thirteen behavioral domains and whether differential frequency of overt behaviors and environmental reward mediated the relationship between gender and depression severity. The sample included 82 undergraduate students [66% females; 84% Caucasian; Mean age = 20.2 years]. Overall, females engaged in a significantly greater breadth of behavioral domains and reported a higher level of environmental reward. Females spent more time in the domains of health/hygiene, spiritual activities, and eating with others. Males spent more time in the domains of physical activity, sexual activity, and hobbies and recreational experiences. Females found social activities, passive/sedentary behaviors, eating with others, and engagement in "other" activities more rewarding. Gender had a significant direct effect on depression severity, with females reporting increased depression. This effect was attenuated by the mediator (total environmental reward) such that to the extent females exhibited increased environmental reward, the gender effect on depression was attenuated. These data support behavioral models of depression, indicate increased reinforcement sensitivity among females, and have clinical relevance in the context of assessment and behavioral activation interventions for depression.

Fishing for happiness: the effects of generating positive imagery on mood and behaviour

Experimental evidence using picture–word cues has shown that generating mental imagery has a causal impact on emotion, at least for images prompted by negative or benign stimuli. It remains unclear whether this finding extends to overtly positive stimuli and whether generating positive imagery can increase positive affect in people with dysphoria. Dysphoric participants were assigned to one of three conditions, and given instructions to generate mental images in response to picture–word cues which were either positive, negative or mixed (control) in valence. Results showed that the positive picture–word condition increased positive affect more than the control and negative conditions. Participants in the positive condition also demonstrated enhanced performance on a behavioural task compared to the two other conditions. Compared to participants in the negative condition, participants in the positive condition provided more positive responses on a homophone task administered after 24 h to assess the durability of effects. These findings suggest that a positive picture–word task used to evoke mental imagery leads to improvements in positive mood, with transfer to later performance. Understanding the mechanisms underlying mood change in dysphoria may hold implications for both theory and treatment development.

Exploring the roles of approach and avoidance in depression: an integrative model

Human behavior can be organized around two fundamental motivational principles: the desire to approach positive outcomes and the desire to avoid negative outcomes. Both approach and avoidance motivation are relevant to a range of psychopathology, including depression. However, with some notable exceptions, avoidance processes have been underemphasized in the literature on motivational processes in depression. This review will examine the roles that approach and avoidance play in depression and will present an integrative model of approach and avoidance processes in depression. Both approach deficits and avoidance motivation are argued to play a role in limiting positive experiences and reinforcement for non-depressed behavior, contributing to the onset and maintenance of depression. In addition, avoidance processes are argued to play a role in negative information processing biases that may increase vulnerability to the onset and recurrence of depression. Lastly, avoidance processes and dysregulation in the connections between the approach and avoidance systems may contribute to depression by promoting inappropriate perseveration in the pursuit of unattainable approach goals. Theoretical rationales and empirical evidence for each of these roles are presented. Understanding the roles that both approach and avoidance play in depression may help to inform current conceptualizations of depression and improve treatment outcomes.

The reward probability index: design and validation of a scale measuring access to environmental reward

Behavioral models of depression implicate decreased response-contingent positive reinforcement (RCPR) as critical toward the development and maintenance of depression (Lewinsohn, 1974). Given the absence of a psychometrically sound self-report measure of RCPR, the Reward Probability Index (RPI) was developed to measure access to environmental reward and to approximate actual RCPR. In Study 1 (n=269), exploratory factor analysis supported a 20-item two-factor model (Reward Probability, Environmental Suppressors) with strong internal consistency (α=.90). In Study 2 (n=281), confirmatory factor analysis supported this two-factor structure and convergent validity was established through strong correlations between the RPI and measures of activity, avoidance, reinforcement, and depression (r=.65 to .81). Discriminant validity was supported via smaller correlations between the RPI and measures of social support and somatic anxiety (r=-.29 to -.40). Two-week test-retest reliability was strong (r=.69). In Study 3 (n=33), controlling for depression symptoms, hierarchical regression supported the incremental validity of the RPI in predicting daily diary reports of environmental reward. The RPI represents a parsimonious, reliable, and valid measure that may facilitate understanding of the etiology of depression and its relationship to overt behaviors.

Behavioral theory of depression: reinforcement as a mediating variable between avoidance and depression

Behavioral theory posits that certain environmental changes and avoidant behaviors inhibit individuals from experiencing environmental reward and reinforcement and subsequently leads to the development and maintenance of depressive symptoms. Using self-report and behavioral (daily diary) indices of environmental reward as proxy measures for positive reinforcement, this investigation examined whether environmental reward mediated the relationship between avoidance and depression. When controlling for anxiety, both indices of environmental reward significantly mediated the relationships of depression with cognitive, behavioral and total avoidance. Post-hoc mediation analyses were conducted to examine potential gender differences. Self-reported environmental reward significantly mediated the relationship between avoidance and depression across both genders. Among females, however, daily diary-measured reward only mediated the relation between cognitive avoidance and depression. In males daily diary reward was a mediator with all three forms of avoidance and depression. This investigation provides initial support for reinforcement as a significant mediator between avoidance and depression and further highlights the relevance of avoidance and reinforcement in behavioral conceptualizations of depression.

Starting a Functional Assessment of Depression (FAD): Development of a FAD

Despite abundance of treatment outcome studies, researchers have failed to identify a treatment for depression that works for all individuals. A possible solution is to individualize depression treatment. To test whether this strategy will be more effective, an assessment tied to theory of intervention is necessary. This article describes a current effort to develop a new measure of depression, the functional assessment of depression (FAD), based on behavioral assessment strategies. A factor analysis and cluster analysis were performed in an attempt to identify information provided that might prove useful in treatment planning. Future efforts to explore the incremental validity and treatment utility of the FAD are described.

Deafblindness and mental health

Using materials adapted for each member, a self-report survey to examine psychological distress and unmet need was sent to the membership of a third sector organization, Deafblind UK. High rates of psychological distress were reported: 61 percent ( n = 439) of the respondents obtained a score of two or more (from a maximum of 12) on the GHQ-12 (Goldberg and Williams, 1988), while 45.8 percent obtained a more stringent score of four or more. The findings also suggested high levels of unmet need: more than one in four respondents (26.9%, n = 504) reported that they received no formal support. Surprisingly, given the important role of primary health care practitioners, both in providing treatment and in accessing other services, only a third (32.1%, n = 504) of respondents reported receiving regular support from a General Practitioner or community nurse. The implications for the development of service provision and practice, particularly within the health service, are discussed.

Measuring homework completion in behavioral activation

The aim of this study was to develop and validate an observer-based coding system for the characterization and completion of homework assignments during Behavioral Activation (BA). Existing measures of homework completion are generally unsophisticated, and there is no current measure of homework completion designed to capture the particularities of BA. The tested scale sought to capture the type of assignment, realm of functioning targeted, extent of completion, and assignment difficulty. Homework assignments were drawn from 12 (mean age = 48, 83% female) clients in two trials of a 10-session BA manual targeting treatment-resistant depression in primary care. The two coders demonstrated acceptable or better reliability on most codes, and unreliable codes were dropped from the proposed scale. In addition, correlations between homework completion and outcome were strong, providing some support for construct validity. Ultimately, this line of research aims to develop a user-friendly, reliable measure of BA homework completion that can be completed by a therapist during session.

The impact of decreased environmental reward in predicting depression severity: support for behavioral theories of depression

Insufficient response-contingent positive reinforcement and decreased environmental reward have been hypothesized to directly contribute to the onset and persistence of depression. The present study examined whether decreased environmental reward was significantly associated with self-reported depression and diagnosed major depression relative to other well-established risk factors that included gender, stressful life events, traumatic life events, childhood maltreatment, and cognitive vulnerability. Based on hierarchical regression analyses, all variables except gender were significantly associated with self-reported depression, and stressful life events, cognitive vulnerability, and decreased environmental reward were associated with diagnosed depression. Of all variables, decreased environmental reward was most strongly related to both self-reported depression and diagnosed clinical depression. The incremental validity of environmental reward in predicting self-reported depression and clinical depression was established, accounting for significant unique variance (12%) in each regression equation. Implications for conceptualizing and treating depression are discussed.

Newer variations of cognitive-behavioral therapy: behavioral activation and mindfulness-based cognitive therapy

Recent innovations in the treatment and prevention of depression that build on the foundation of cognitive-behavioral therapy represent promising directions for clinical practice and research. Specifically, behavioral activation and mindfulness-based cognitive therapy have been a recent focus of attention. Behavioral activation is a brief, structured approach to treating acute depression that seeks to alleviate depression by promoting an individual's contact with sources of reward through increasing activation, improving problem solving, and decreasing avoidance and other barriers to activation. Mindfulness-based cognitive therapy is a brief group intervention that seeks to prevent depressive relapse by promoting mindful attention, acceptance, and skillful action to help individuals interrupt habitual cognitive and affective patterns associated with risk of relapse. Each approach is supported by at least two large-scale, randomized clinical trials; however, many important questions remain. We examine current research on both approaches by addressing the robustness of findings, the extension to novel populations, and the processes by which clinical benefit is achieved.