Reductions in negative repetitive thinking and metacognitive beliefs during transdiagnostic internet cognitive behavioural therapy (iCBT) for mixed anxiety and depression

Efficacy of internet-delivered universal and tailored transdiagnostic interventions for anxiety and depression: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Internet-delivered transdiagnostic psychological interventions are promising approaches for the treatment of anxiety and depression. This study aimed to review and synthesize evidence related to the effectiveness of Internet-based transdiagnostic interventions for reducing anxiety and depression, and to compare the effects of universal versus tailored interventions.

METHODS

A Systematic review search was conducted on the PubMed, EMBASE, Cochrane Library, Web of Science, PsychINFO, Medline, and CINAHL databases as of 28 March 2024. Two researchers made their choices based on consensus. This study performed a random-effects meta-analysis comparing patients receiving Internet-based transdiagnostic therapy with a control group, and examined the effects on depression, anxiety, and quality of life. This meta-analysis compared the effect of Internet-delivered universal and tailored transdiagnostic on anxiety and depression.

RESULTS

42 trials were identified with a total of 4982 participants. Compared with the control group, the Internet-delivered transdiagnostic intervention reduced anxiety and depression symptoms (g = -0.617, 95 % CI: -0.699 to -0.535), anxiety (g = -0.580, 95 % CI: -0.690 to -0.470), depression (g = -0.650, 95 % CI: -0.770 to -0.530). The Internet-delivered universal transdiagnostic treatment was more effective than tailored transdiagnostic in improving anxiety and depression. Internet-delivered transdiagnostic interventions also had a positive impact on quality of life (g = 0.310; 95 % CI: 0.130 to 0.490).

CONCLUSIONS

This meta-analysis demonstrates that Internet-based transdiagnostic interventions are effective for treating anxiety and depression, and can also improve quality of life. The universal Internet-delivered transdiagnostic intervention is better than the tailored intervention. Future studies should investigate the mechanisms of change and develop outcome measures for these interventions.

Mechanisms of change in digital interventions for depression: A systematic review and meta-analysis of six mediator domains

BACKGROUND

While the efficacy of digital interventions for the treatment of depression is well established, comprehensive knowledge on how therapeutic changes come about is still limited. This systematic review aimed to provide an overview of research on change mechanisms in digital interventions for depression and meta-analytically evaluate indirect effects of potential mediators.

METHODS

The databases CENTRAL, Embase, MEDLINE, and PsycINFO were systematically searched for randomized controlled trials investigating mediators of digital interventions for adults with depression. Two reviewers independently screened studies for inclusion, assessed study quality and categorized potential mediators. Indirect effects were synthesized with a two-stage structural equation modeling approach (TSSEM).

RESULTS

Overall, 25 trials (8110 participants) investigating 84 potential mediators were identified, of which attentional (8 %), self-related (6 %), biophysiological (6 %), affective (5 %), socio-cultural (2 %) and motivational (1 %) variables were the scope of this study. TSSEM revealed significant mediation effects for combined self-related variables (ab = -0.098; 95 %-CI: [-0.150, -0.051]), combined biophysiological variables (ab = -0.073; 95 %-CI: [-0.119, -0.025]) and mindfulness (ab = -0.042; 95 %-CI: [-0.080, -0.015]). Meta-analytical evaluations of the other three domains were not feasible.

LIMITATIONS

Methodological shortcomings of the included studies, the considerable heterogeneity and the small number of investigated variables within domains limit the generalizability of the results.

CONCLUSION

The findings further the understanding of potential change mechanisms in digital interventions for depression and highlight recommendations for future process research, such as the consideration of temporal precedence and experimental manipulation of potential mediators, as well as the application of network approaches.

Neuroticism and cognitive correlates of depression and anxiety in endometriosis: A meta-analytic review, evidence appraisal, and future recommendations

OBJECTIVE

This meta-analytic review aimed to synthesise evidence on personality and cognitive factors related to depression and anxiety in endometriosis and determine whether sociodemographic and clinical variables moderate factor-symptom relations. Additionally, this review aimed to evaluate the quality of research and formulate recommendations for future research.

METHODS

A systematic search was conducted across databases (Medline, Embase, PsycInfo, Web of Science, ProQuest) through to February 2024. Search terms were used for endometriosis, depression, anxiety, cognitive factors and personality traits. Random-effects meta-analyses were conducted to produce pooled weighted effects (r) for factor-symptom relationships.

RESULTS

Thirteen studies (11 samples; N = 3287; Mage 33.89 ± 2.48) were included in a narrative synthesis. One study provided evidence for a positive association between neuroticism and depression. Seven studies contributed to meta-analyses on three cognitive factors. Medium-to-large associations were identified between illness perceptions of low control/power (r = 0.35, 95 % CI: 0.01,0.62), rumination (r = 0.52, 95 % CI: 0.09, 0.78), pain-catastrophising (r = 0.37, 95 % CI: 0.28, 0.45) and higher levels of depression. The statistical power to detect significant effects was >80 %. Findings for anxiety were non-significant, although limited data were available. Quality appraisal revealed a high risk of within-study bias (4.69 ± 1.38, range: 3-7), with issues related to sample representativeness and measurement selection.

CONCLUSION

Rumination, pain-catastrophising, and illness perceptions of low control/power are important in understanding depression in endometriosis. There is a lack of research on personality traits, necessitating further study. Findings highlight the importance of prioritising modifiable cognitive factors in psychological research and clinical practice in endometriosis.

Efficacy of a transdiagnostic Internet prevention approach in adolescents (EMPATIA study): study protocol of a randomized controlled trial

BACKGROUND

Most mental disorders have their onset in adolescence. Preventive interventions during this period are important; however, help-seeking behavior is generally poor in this age group resulting in low treatment rates. Internet interventions are expected to be an effective, low-threshold, and scalable approach to overcome barriers to help-seeking, particularly for individuals experiencing subclinical symptoms. Internet-delivered indicated prevention seems promising as it targets individuals with minimal symptoms of mental disorders who might need care but are not help-seeking yet. Previous indicated prevention-approaches have mainly targeted specific risk-syndromes. However, this contradicts the increasing recognition of emerging psychopathology as a complex system characterized by co-occurrence and rapid shifts of subclinical symptoms cutting across diagnostic categories. Therefore, this study will investigate the efficacy, mediators, moderators, and core symptomatic changes of a transdiagnostic Internet-delivered indicated prevention program (EMPATIA program) for adolescents.

METHODS

This randomized controlled trial (RCT) will be conducted in a general population sample (planned n = 152) of adolescents aged 12-18 years with subclinical symptoms but without any current or past mental disorder. Participants will be randomly assigned to the EMPATIA program or a care as usual (CAU) control condition. The 8-week guided EMPATIA program encompasses 8 modules targeting the following transdiagnostic mechanisms: repetitive negative thinking, self-perfectionism, emotion regulation, intolerance of uncertainty, rejection sensitivity, and behavioral avoidance. Participants will be asked to answer online self-report questionnaires at baseline, after 8 weeks, and at 6-, 9-, and 12-month follow-up. Diagnostic telephone interviews will be conducted at baseline and at 12-month follow-up. Additionally, intervention-specific constructs (motivation, alliance, negative effects, satisfaction, adherence) will be assessed during and after the EMPATIA program. The level of self-reported general psychopathology post-intervention is the primary outcome.

DISCUSSION

Results will be discussed considering the potential of Internet interventions as a scalable, low-threshold option for indicated prevention in adolescents experiencing subclinical symptoms. The EMPATIA program introduces a novel Internet prevention program targeting six transdiagnostic mechanisms associated with various mental health outcomes. Thereby, this trial pursues a very timely and important topic because it may contribute to narrow the current care gap for adolescents, to prevent mental health problems and related negative consequences, and to promote mental health in the long-term.

TRIAL REGISTRATION

The trial was approved by Swissmedic (Registration Number: 10001035, 08/22/2022) and the Ethics Committee of Bern (Registration Number: 2022-D0036, 08/22/2022). The trial was registered at ClinicalTrials.gov NCT05934019 on 07-03-2023.

Understanding How Green Space Naturalness Impacts Public Well-Being: Prospects for Designing Healthier Cities

Statement of problem: Urbanization has brought significant advancements in human well-being; however, it poses challenges to urban green spaces (UGSs), affecting environmental quality and public health. Research gap: Previous studies have established the importance of UGSs for urban well-being but have not sufficiently explored how the naturalness of these spaces-ranging from untouched natural areas to human-designed landscapes-affects mental health outcomes in the context of developing countries, particularly Brazil. Purpose: This study aimed to bridge the research gap by investigating the relationship between the degree of naturalness in UGSs and mental health among residents of Brazilian metropolitan areas. Method: Data were collected through an online survey involving 2136 respondents from various Brazilian urban regions. The study used Welch's ANOVA and Games-Howell post hoc tests to analyze the impact of UGS naturalness on mental health, considering depression, anxiety, and stress levels. Results and conclusions: The findings revealed that higher degrees of naturalness in UGSs significantly correlate with lower levels of mental distress. These results underscore the necessity of integrating natural elements into urban planning to enhance public health. Practical implications: Urban planners and policymakers are encouraged to prioritize the preservation and creation of naturalistic UGSs in urban environments to improve mental health outcomes. Future directions: Further research should explore the specific attributes of naturalness that most contribute to well-being and examine the scalability of these findings across different cultural and environmental contexts.

The role of rumination in the relationship between symptoms of insomnia and depression in adolescents

There is a strong relationship between the symptoms of insomnia and depression, however, little is understood about the factors that mediate this relationship. An understanding of these underlying mechanisms may inform the advancement of existing treatments to optimise reductions in insomnia and depression when they co-occur. This study examined rumination and unhelpful beliefs about sleep as mediators between symptoms of insomnia and depression. It also evaluated the effect of cognitive behavioural therapy for insomnia (CBT-I) on rumination and unhelpful beliefs about sleep, and whether these factors mediated the effect of CBT-I on depressive symptoms. A series of mediation analyses and linear mixed modelling were conducted on data from 264 adolescents (12-16 years) who participated in a two-arm (intervention vs. control) randomised controlled trial of Sleep Ninja®, a CBT-I smartphone app for adolescents. Rumination, but not unhelpful beliefs about sleep, was a significant mediator between symptoms of insomnia and depression at baseline. CBT-I led to reductions in unhelpful beliefs about sleep, but not in rumination. At the between-group level, neither rumination, nor unhelpful beliefs about sleep emerged as mechanisms underlying improvement in depression symptoms, however, rumination mediated within-subject improvements following CBT-I. The findings suggest rumination links symptoms of insomnia and depression and provide preliminary evidence that reductions in depression following CBT-I occurs via improvements in rumination. Targeting rumination may improve current therapeutic approaches.

Predictive Model of Anxiety and Depression Perception in Multiple Sclerosis Patients: Possible Implications for Clinical Treatment

Multiple Sclerosis (MS) is a neurodegenerative disease characterized by motor and non-motor symptoms, including emotional distress, anxiety, and depression. These emotional symptoms currently have a pharmacological treatment with limited effectiveness; therefore, it is necessary to delve into their relationship with other psychological, functional, or prefrontal alterations. Additionally, exploring non-pharmacological therapeutic alternatives that have shown benefits in addressing emotional distress in MS patients is essential.

AIM

To establish a predictive model for the presence of anxiety and depression in MS patients, based on variables such as psychological well-being, functional activity, and prefrontal symptoms. Additionally, this study aimed to propose non-pharmacological therapeutic alternatives based on this model.

MATERIALS AND METHODS

A descriptive, observational, and cross-sectional study was conducted with a sample of 64 diagnosed MS patients who underwent functional and cognitive assessments using the following questionnaires and scales: Functional Activities Questionnaire (FAQ), Acceptance and Action Questionnaire (AAQ-II), Experiences Questionnaire (EQ), Self-Compassion Scale Short Form (SCS-SF), Beck Depression Inventory II (BDI-II), State-Trait Anxiety Inventory (STAI), and Prefrontal Symptoms Inventory (PSI).

RESULTS

The model showed an excellent fit to the data and indicated that psychological well-being was the most significant predictor of the criteria (β = -0.83), followed by functional activity (β = -0.18) and prefrontal symptoms (β = 0.15). The latter two are negatively related to psychological well-being (β = -0.16 and β = -0.75, respectively).

CONCLUSIONS

Low psychological well-being is the variable that most significantly predicts the presence of anxiety and depression in MS patients, followed by functional activity and prefrontal alterations. Interventions based on mindfulness and acceptance are recommended, along with nutritional interventions such as antioxidant-enriched ketogenic diets and moderate group physical exercise.

Tailored internet-based psychological treatment for psychological problems during the COVID-19 pandemic: A randomized controlled trial

The COVID-19 pandemic influence mental health in both infected and non-infected populations. In this study we examined if individually tailored internet-based cognitive behavioral therapy (ICBT) could be an effective treatment for psychological symptoms related to the pandemic. Following recruitment we included 76 participants who were randomized to either a treatment group (n = 37) or a waitlist control group (n = 39). The treatment group received 8 modules (out of 16 possible) during 8 weeks with weekly therapist support. We collected data on symptoms of depression, experienced quality of life, anxiety, stress, anger, insomnia, PTSD, and alcohol use before, after the treatment and at one year follow-up. Using multiple regression analysis, group condition was found to be a statistically significant predictor for a decrease, favoring the treatment group, in symptoms of depression, insomnia, and anger with small to moderate effect sizes. The improvements remained at one year follow-up. Group condition did not significantly predict changing symptoms regarding experienced quality of life, anxiety, stress, PTSD and alcohol use. Findings indicate that ICBT is an effective intervention for some psychological symptoms associated with the COVID-19 pandemic. There is a need for further studies on mechanisms of change and on tailored ICBT for problems associated with crises like the pandemic.

An observational treatment study of metacognition in anxious-depression

Prior studies have found metacognitive biases are linked to a transdiagnostic dimension of anxious-depression, manifesting as reduced confidence in performance. However, previous work has been cross-sectional and so it is unclear if under-confidence is a trait-like marker of anxious-depression vulnerability, or if it resolves when anxious-depression improves. Data were collected as part of a large-scale transdiagnostic, four-week observational study of individuals initiating internet-based cognitive behavioural therapy (iCBT) or antidepressant medication. Self-reported clinical questionnaires and perceptual task performance were gathered to assess anxious-depression and metacognitive bias at baseline and 4-week follow-up. Primary analyses were conducted for individuals who received iCBT (n=649), with comparisons between smaller samples that received antidepressant medication (n=82) and a control group receiving no intervention (n=88). Prior to receiving treatment, anxious-depression severity was associated with under-confidence in performance in the iCBT arm, replicating previous work. From baseline to follow-up, levels of anxious-depression were significantly reduced, and this was accompanied by a significant increase in metacognitive confidence in the iCBT arm (β=0.17, SE=0.02, p<0.001). These changes were correlated (r(647)=-0.12, p=0.002); those with the greatest reductions in anxious-depression levels had the largest increase in confidence. While the three-way interaction effect of group and time on confidence was not significant (F(2, 1632)=0.60, p=0.550), confidence increased in the antidepressant group (β=0.31, SE = 0.08, p<0.001), but not among controls (β=0.11, SE = 0.07, p=0.103). Metacognitive biases in anxious-depression are state-dependent; when symptoms improve with treatment, so does confidence in performance. Our results suggest this is not specific to the type of intervention.

Efficacy of an internet-based cognitive behavioral therapy for subthreshold depression among Chinese adults: a randomized controlled trial

BACKGROUND

Subthreshold depression (sD) negatively impacts well-being and psychosocial function and is more prevalent compared with major depressive disorder (MDD). However, as adults with sD are less likely to seek face-to-face intervention, internet-based cognitive-behavioral therapy (ICBT) may overcome barriers of accessibility to psychotherapy. Although several trials explored the efficacy of ICBT for sD, the results remain inconsistent. This study evaluated whether ICBT is effective in reducing depressive symptoms among Chinese adults with sD.

METHODS

A randomized controlled trial was performed. The participants were randomly assigned to 5 weeks of ICBT, group-based face-to-face cognitive-behavioral therapy (CBT), or a waiting list (WL). Assessments were conducted at baseline, post-intervention and at a 6-month follow-up. The primary outcome measured depressive symptoms using the Center for Epidemiological Studies Depression Scale (CES-D). Outcomes were analyzed using a mixed-effects model to assess the effects of ICBT.

RESULTS

ICBT participants reported greater reductions on all the outcomes compared to the WL group at post-intervention. The ICBT group showed larger improvement on the Patient Health Questionnaire-9 (PHQ-9) at post-intervention (d = 0.12) and at follow-up (d = 0.10), and with CES-D at post-intervention (d = 0.06), compared to the CBT group.

CONCLUSIONS

ICBT is effective in reducing depressive symptoms among Chinese adults with sD, and improvements in outcomes were sustained at a 6-month follow-up. Considering the low rates of face-to-face psychotherapy, our findings highlight the considerable potential and implications for the Chinese government to promote the use of ICBT for sD in China.

The impact of technology systems and level of support in digital mental health interventions: a secondary meta-analysis

BACKGROUND

The majority of people with a chronic disease (e.g., diabetes, hypertension, COPD) have more than one concurrent condition and are also at higher risk for developing comorbidities in mental health, including anxiety and depression. There is an urgent need for more relevant and accurate data on digital interventions in this area to prepare for an increase demand for mental health services. The aim of this study was to conduct a meta-analysis of the digital mental health interventions for people with comorbid physical and mental chronic diseases to compare the effect of technology systems and level of support.

METHODS

This secondary meta-analysis follows a rapid review of systematic reviews, a virtual workshop with knowledge users to identify research questions and a modified Delphi study to guide research methods: What types of digital health interventions (according to a recognized categorization) are the most effective for the management of concomitant mental health and chronic disease conditions in adults? We conducted a secondary analysis of the primary studies identified in the rapid review. Two reviewers independently screened the titles and abstracts and applied inclusion criteria: RCT design using a digital mental health intervention in a population of adults with another chronic condition, published after 2010 in French or English, and including an outcome measurement of anxiety or depression.

RESULTS

Seven hundred eight primary studies were extracted from the systematic reviews and 84 primary studies met the inclusion criteria Digital mental health interventions were significantly more effective than in-person care for both anxiety and depression outcomes. Online messaging was the most effective technology to improve anxiety and depression scores; however, all technology types were effective. Interventions partially supported by healthcare professionals were more effective than self-administered.

CONCLUSIONS

While our meta-analysis identifies digital intervention's characteristics are associated with better effectiveness, all technologies and levels of support could be used considering implementation context and population.

TRIAL REGISTRATION

The protocol for this review is registered in the National Collaborating Centre for Methods and Tools (NCCMT) COVID-19 Rapid Evidence Service (ID 75).

Preliminary examination of acceptability, feasibility, and effectiveness of internet-based cognitive behavioral therapy for treatment of depression and anxiety in infertile women

Background

Despite a large body of evidence supporting the effectiveness of internet-based cognitive behavior therapy (ICBT) for the treatment of depression and anxiety, there is no report of the efficacy of ICBT program in the Iranian population. The present study aimed to test the acceptability, feasibility, and effectiveness of ICBT program for the treatment of depression or anxiety in infertile women.

Method

This study consisted of two phases. In the first phase, we designed "Peaceful Mind", an eight-session therapist-guided ICBT program. In the second phase, we tested the efficacy of the program by conducting 2-arm parallel group, non-inferiority randomized control trial, between October 2020 and July 2021.60 infertile women diagnosed with depression or anxiety disorders were divided randomly to ICBT treatment (n = 30) and face-to face CBT (n = 30). The participants received individual CBT sessions (60 min, over 8 weeks) and completed the questionnaires at the beginning, in mid-trial, and 8 weeks after the trial. The outcomes comprised Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI, Fertility problem inventory (FPI), Client Satisfaction Questionnaire (CSQ-8), and System usability scale (SUS).

Results

The usability scores of the "Peaceful Mind" ICBT (M = 67.07, SD = 17.23, range = 1-100) and satisfaction with the treatment (M = 25.06, SD = 4.18, range = 1-32) were high. Patient adherence to the treatment in the ICBT group (86.6%) was the same as that in the CBT (73.3%). The between-group mean differences at the post-trial were -4.79 (CI 95% = -10.81 to 1.23) for depression scores and -4.15 (CI 95% = -9.52 to 1.22) for anxiety scores; both differences were within the non-inferiority margin points for the lower 95%CI.

Conclusion

"Peaceful mind" ICBT was found to be feasible and accessible for delivering the treatment to the patients. The study confirmed that both ICBT face-to face CBT were equally effective in reducing depression and anxiety of the patients.

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

Are Changes in Beliefs About Rumination and in Emotion Regulation Skills Mediators of the Effects of Internet-Delivered Cognitive-Behavioral Therapy for Depression and Anxiety? Results from a Randomized Controlled Trial

Background

Internet-delivered cognitive behavior therapy (iCBT) is effective in treating anxiety and depression. Research on how these interventions operate is scarce. This study explored whether emotion regulation skills and positive beliefs about rumination were affected by iCBT and if these constructs mediated changes in depression and anxiety.

Methods

This is a secondary analysis of a pragmatic randomized waitlist-controlled trial testing the effectiveness of supported iCBT. Adults with at least mild symptoms of depression or anxiety were included. Depression (PHQ-9), anxiety (GAD-7), positive beliefs about rumination (PBRS-A) and two emotion regulation skills: cognitive reappraisal (ERQ-A) and expressive suppression (ERQ-S), were measured at baseline and 8-weeks post-treatment.

Results

The analyses included 358 participants, 71% were female. Median age was 29. Linear mixed models showed statistically significant differences along ERQ-A in favor of the iCBT group (b = 1.83, SE = 0.82, p = .026). Mediation analyses showed reductions in depression (b = 0.31, SE = 0.15, p = 0.043) and anxiety symptoms (b = 0.27, SE = 0.14, p = 0.057) were partially mediated by gains in ERQ-A. No effects were observed for PBRS-A and ERQ-S.

Conclusions

These results align with findings from face-to-face therapy and add to the scarce literature on mediators of effects of iCBT, contributing to the understanding of how these interventions operate. Since mediator and outcome variables were measured at the same time, partial mediation results should be interpreted with caution since the study design did not account for temporality and therefore causality effects cannot be confirmed.

Trial Registration

ISRCTN91967124.

Support for a non-therapist assisted, Internet-based cognitive-behavioral therapy (iCBT) intervention for mental health in rheumatoid arthritis patients

BACKGROUND

Anxiety is common in patients with rheumatoid arthritis (RA) and associated with worse RA outcomes. This study assessed the feasibility and preliminary health impacts (mental and physical) of a non-therapist assisted, online mental health intervention targeting anxiety in this population.

METHODS

Participants with confirmed RA and elevated anxiety symptoms were enrolled into the Worry and Sadness program, an Internet-based cognitive-behavioral therapy (iCBT) intervention for anxiety and depression shown to be effective in the general population. Validated self-report measures of anxiety, depression, pain interference, fatigue, physical health-related quality of life, functional status, and patient-reported disease severity were collected at baseline, post-intervention, and at three-month follow-up. Emotional distress scores were tracked between lessons. Participants provided qualitative feedback in writing post-intervention.

RESULTS

We analyzed the responses of 34 participants; the majority was female (86%) and the mean age was 57 (SD = 13). Of these, 80% (n = 28) completed the study in its entirety. Among these completers, 94.1% described the program as worthwhile. We found statistically significant improvements in anxiety, depression and fatigue from baseline to three-month follow-up, with small to large effect sizes (d = 0.39-0.81). Post-hoc analyses revealed that statistically significant change occurred between baseline and post-intervention for anxiety and depression and was maintained at three-month follow-up, whereas statistically significant change occurred between baseline and three-month follow-up for fatigue. Statistically significant reductions in emotional distress occurred across the program, with a large effect size (d = 1.16) between the first and last lesson.

CONCLUSION

The Worry and Sadness program shows promise as a feasible resource for improving mental health in RA.

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Evaluating the empirical evidence for three transdiagnostic mechanisms in anxiety and mood disorders

High co-morbidity among mental disorders indicates that common transdiagnostic mechanisms underlie various psychopathology, yet there has been little research effort to empirically explicate transdiagnostic processes. A few existing studies are limited in the number of transdiagnostic mechanisms and mental disorder categories explored. The current study addresses these limitations by examining the relationship between three transdiagnostic processes (experiential avoidance, rumination, and emotion dysregulation) and symptom severity of five mental disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and depression) in a college sample (N = 266). Applying Structural Equation Modeling (SEM), three transdiagnostic models were evaluated, with the five latent variables of mental disorder regressed onto each transdiagnostic process. The results showed that all transdiagnostic models-except the emotion dysregulation model-generally fit the data well. Among the tested models, the strongest evidence was found for experiential avoidance as a transdiagnostic mechanism underlying multiple disorders, suggesting the need for further research effort to reduce experiential avoidance in diverse clinical populations.

Depressive symptoms, ruminative thinking, marijuana use motives, and marijuana outcomes: A multiple mediation model among college students in five countries

BACKGROUND

Previous studies have evidenced that rumination and drinking motives may mediate the association between depressive symptoms and alcohol outcomes. The present study cross-culturally examined whether a similar mediation model may extend to marijuana. Specifically, we tested distinct rumination facets (problem-focused thoughts, counterfactual thinking, repetitive thoughts, and anticipatory thoughts) and marijuana use motives (social, coping, expansion, conformity, enhancement) as double-mediators of the paths from depressive symptoms to marijuana outcomes (use and consequences).

METHOD

A comprehensive mediation path model was tested in a cross-sectional sample of college student marijuana users (n = 1175) from five countries (U.S., Argentina, Uruguay, Spain, Netherlands). Multi-group models were tested to determine if the proposed mediational model was invariant across sex and different cultures/countries.

RESULTS

Depressive symptoms and marijuana outcomes were indirectly associated through ruminative thinking and marijuana motives. Specifically, higher depressive symptoms were associated with higher problem-focused thoughts; which in turn were associated with: a) higher endorsement of coping motives which in turn was associated with higher marijuana use and related consequences and b) lower endorsement of enhancement motives which in turn was associated with lower marijuana use and related consequences. The multi-group analyses showed that the model was invariant across sex and the five countries.

CONCLUSIONS

The present research supports the existence of a universal (i.e., cross-national invariant) negative affect regulation pathway to marijuana use/misuse similar to those previously found with alcohol. Additional research is needed to confirm the role of enhancement motives in the associations of depression, rumination and marijuana outcomes.

Is repetitive negative thinking a transdiagnostic process? A comparison of key processes of RNT in depression, generalized anxiety disorder, obsessive-compulsive disorder, and community controls

BACKGROUND AND OBJECTIVES

The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD).

METHODS

Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance.

RESULTS

All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT.

LIMITATIONS

Results are based on retrospective self-reports, which might restrict validity of the measurements.

CONCLUSIONS

Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.

Exploring Mediators of a Guided Web-Based Self-Help Intervention for People With HIV and Depressive Symptoms: Randomized Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is frequently used to treat depressive symptoms in people living with HIV. We developed an internet-based cognitive behavioral intervention for people with HIV and depressive symptoms, which was based on an effective self-help booklet. The Web-based intervention was previously found to be effective.

OBJECTIVE

The objective of this study was to investigate potential mediators of the Web-based intervention.

METHODS

This study was part of a randomized controlled trial, in which the intervention was compared with an attention-only waiting list control condition. Participants were 188 (97 in intervention group and 91 in control group) people with HIV and mild to moderate depressive symptoms recruited in HIV treatment centers in the Netherlands. A total of 22 participants (22/188, 11.7%) in the study were female and 166 (166/188, 88.3%) were male. The average age of the participants was 46.30 years (SD 10.63). The intervention comprised Web-based self-help CBT for 8 weeks, 1 to 2 hours a week, including minimal telephone support from a coach. The participants received Web-based questionnaires at pretest, 3 times during the intervention/or waiting period, and post intervention. The outcome was depressive symptoms. Factors tested as potential mediators were changes in behavioral activation, relaxation, the cognitive coping strategies catastrophizing and positive refocusing, goal re-engagement, and coping self-efficacy.

RESULTS

Using multilevel structural equation modeling, changes in behavioral activation (P=.006) and goal re-engagement (P=.009) were found to be significant mediators of the intervention effect. The mediation effect seemed to occur between weeks 3 and 5 for behavioral activation and weeks 1 and 3 for goal re-engagement. Using (bivariate) autoregressive latent trajectory analysis, we found a return effect (from the dependent variable to the mediator) for goal re-engagement but not for behavioral activation, which suggested that the mediation effect of changes in behavioral activation was stronger than that in goal re-engagement.

CONCLUSIONS

The results suggest that changes in behavioral activation and goal re-engagement may mediate the effect of the Web-based intervention for people with HIV and depressive symptoms. The results may lead to possible mechanisms of change of the intervention and improvement of therapy outcomes.

TRIAL REGISTRATION

Netherlands Trial Register NTR5407; https://www.trialregister.nl/trial/5298.

Mediation analyses of Internet-facilitated cognitive behavioral intervention for maternal depression

This study evaluated the putative mediating mechanisms of an Internet-facilitated cognitive-behavioral therapy (CBT) intervention for depression tailored to economically disadvantaged mothers of preschool-age children. The CBT mediators were tested across two previously published randomized controlled trials which included the same measures of behavioral activation, negative thinking, and savoring of positive events. Trial 1 included 70 mothers with elevated depressive symptoms who were randomized to either the eight-session, Internet-facilitated intervention (Mom-Net) or to treatment as usual. Trial 2 included 266 mothers with elevated depressive symptoms who were randomized to either Mom-Net or to a motivational interviewing and referral to services condition. Simple mediation models tested each putative mediator independently followed by tests of multiple mediation that simultaneously included all three mediators in the model to assess the salient contributions of each mediator. The pattern of results for the mediating effects were systematically replicated across the two trials and suggest that behavioral activation and negative thinking are salient mediators of the Mom-Net intervention; significant mediating effects for savoring were obtained only in the simple mediation models and were not obtained in the multiple mediation models.

Efficacy of an internet and app-based gratitude intervention in reducing repetitive negative thinking and mechanisms of change in the intervention's effect on anxiety and depression: Results from a randomized controlled trial

Repetitive negative thinking (RNT) has been identified as a transdiagnostic process that is involved in various forms of psychopathology, including anxiety and depression. This randomized controlled trial compared a 5-week internet and app-based gratitude intervention (intervention group; IG) with adherence-focused guidance against a wait list control group (WLG) in reducing RNT in a sample with elevated RNT.

METHOD

A total of 260 individuals were randomized to either the IG or the WLG. Data were collected at baseline (T1), within one week post intervention (T2), and at three (3-MFU) and six-months of follow-up (6-MFU; for IG only). The primary outcome was RNT. Secondary outcomes included other mental health outcomes and resilience factors.

RESULTS

Participants of the IG reported significantly less RNT at T2 (d = 0.61) and 3-MFU (d = 0.75) as compared to WLG. Improvements were sustained until 6-MFU. Significant, small to moderate effect sizes were identified for most secondary outcomes at T2 and 3-MFU. Furthermore, results of mediation analyses revealed that the gratitude intervention exerts its effect on anxiety and depression by reducing the risk factor of RNT, while the mediating role of resilience was less clear.

CONCLUSIONS

The gratitude intervention investigated in this study was found to be effective in reducing RNT. Gratitude interventions might affect mental health by two parallel pathways: increasing resources and reducing risk factors.

REFERENCE NUMBER ETHICS COMMITTEE OF THE UNIVERSITY OF LUENEBURG

EB 201701-03-Lehr.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS00011862. The trial protocol can be assessed at: https://www.drks.de/.

Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial

Transdiagnostic internet-delivered cognitive behavioural therapies (iCBT) are effective for treating anxiety and depression, but there is room for improvement. In this study we developed a new Mindfulness-Enhanced iCBT intervention by incorporating formal and informal mindfulness exercises within an existing transdiagnostic iCBT program for mixed depression and anxiety. We examined the acceptability, feasibility, and outcomes of this new program in a sample of 22 adults with anxiety disorders and/or major depression. Participants took part in the 7-lesson clinician-guided online intervention over 14 weeks, and completed measures of distress (K-10), anxiety (GAD-7), depression (PHQ-9), mindfulness (FFMQ) and well-being (WEMBWS) at pre-, mid-, post-treatment, and three months post-treatment. Treatment engagement, satisfaction, and side-effects were assessed. We found large, significant reductions in distress (Hedges g = 1.55), anxiety (g = 1.39), and depression (g = 1.96), and improvements in trait mindfulness (g = 0.98) and well-being (g = 1.26) between baseline and post-treatment, all of which were maintained at follow-up. Treatment satisfaction was high for treatment-completers, with minimal side-effects reported, although adherence was lower than expected (59.1% completed). These findings show that it is feasible to integrate online mindfulness training with iCBT for the treatment of anxiety and depression, but further research is needed to improve adherence. A randomised controlled trial is needed to explore the efficacy of this program.

Fear of cancer recurrence and death anxiety

In 2013, 3 systematic reviews of fear of cancer recurrence (FCR) and its predictors were published. All 3 concurred that FCR is a highly prevalent problem and amongst the largest unmet needs of cancer survivors, even 5 or more years after treatment. However, between them they identified only 1 study that had investigated the relationship between death anxiety and FCR. This is surprising because it is well acknowledged that a diagnosis of cancer, a potentially life-threatening illness, is associated with a number of existential issues that give rise to psychological sequelae such as intrusive thoughts about death and other post-traumatic symptoms. Outside the cancer literature, there has recently been a call to identify death anxiety as a transdiagnostic construct that underlies many anxiety disorders even in healthy people. And yet, the relevance of death anxiety to FCR has not been studied. We explore the barriers to the study of death anxiety and FCR and the reasons that a potential link between the 2 might have important theoretical and clinical implications. We conclude that establishing the relationship between death anxiety, FCR and other existential issues is essential in order to fully understand FCR, particularly in the context of advanced disease. We further conclude that whether death anxiety underlies FCR has important clinical implications which would potentially allow us to optimise currently available evidence-based treatments.

Efficacy of Guided iCBT for Depression and Mediation of Change by Cognitive Skill Acquisition

Guided internet CBT (iCBT) is a promising treatment for depression; however, it is less well known through what mechanisms iCBT works. Two possible mediators of change are the acquisition of cognitive skills and increases in behavioral activation. We report results of an 8-week waitlist controlled trial of guided iCBT, and test whether early change in cognitive skills or behavioral activation mediated subsequent change in depression. The sample was 89 individuals randomized to guided iCBT (n = 59) or waitlist (n = 30). Participants were 75% female, 72% Caucasian, and 33 years old on average. The PHQ9 was the primary outcome measure. Mediators were the Competencies of Cognitive Therapy Scale-Self Report and the Behavioral Activation Scale for Depression-Short Form. Treatment was Beating the Blues plus manualized coaching. Outcomes were analyzed using linear mixed models, and mediation with a bootstrap resampling approach. The iCBT group was superior to waitlist, with large effect sizes at posttreatment (Hedges' g = 1.45). Dropout of iCBT was 29% versus 10% for waitlist. In the mediation analyses, the acquisition of cognitive skills mediated subsequent depression change (indirect effect = -.61, 95% bootstrapped biased corrected CI: -1.47, -0.09), but increases in behavioral activation did not. iCBT is an effective treatment for depression, but dropout rates remain high. Change in iCBT appears to be mediated by improvements in the use of cognitive skills, such as critically evaluating and restructuring negative thoughts.

Reducing behavioral avoidance with internet-delivered cognitive behavior therapy for generalized anxiety disorder

Recent research has sought to identify maladaptive behaviors that are associated with generalized anxiety disorder (GAD). Although maladaptive behaviors may contribute to the maintenance of the disorder, little is known about how these behaviors change during the course of cognitive behavior therapy and whether such changes relate to treatment outcomes. This study examined changes in maladaptive behaviors, symptoms of GAD and depression, and disability across internet-based cognitive behavior therapy (iCBT) for GAD in two large clinical samples (N = 206 and 298). Assessments were completed at pre and post-treatment. Significant reductions in patients' maladaptive behaviors (WBI), GAD and depression severity (GAD-7 and PHQ-9), and disability (WHODAS-II) were observed following iCBT. Reductions in maladaptive behaviors predicted post-treatment GAD symptom severity after controlling for pre-treatment GAD symptom severity and reductions in depression and disability. Findings provide further support for the importance of maladaptive behaviors in contemporary conceptualizations of GAD and highlight the need for experimental investigations to examine the possible causal relationships between maladaptive behaviors and GAD.

Relationships Between Refraining From Catastrophic Thinking, Repetitive Negative Thinking, and Psychological Distress

Skills to refrain from catastrophic thinking were negatively related to worry and a wide range of psychological distress. Repetitive negative thinking (including worry) is proposed as a common etiological factor for a wide range of psychological distress. Therefore, reduced repetitive negative thinking would mediate the negative relation between refraining from catastrophic thinking and psychological distress (depression, social anxiety, phobia, generalized anxiety, and obsessions and compulsions). As an overlap between five indices of psychological distress was expected, we first computed latent factors underlying them, which were then predicted by refraining from catastrophic thinking and repetitive negative thinking. Cross-sectional questionnaire data from 125 nonclinical voluntarily participating students ( M age = 19.0 years, SD = 3.6; 54% women) supported the predictions: refraining from catastrophic thinking was negatively correlated with depression, social anxiety, phobia, generalized anxiety, and obsession and compulsion. Repetitive negative thinking mediated the negative relationship between refraining from catastrophic thinking and latent factors underlying psychological distress (Fear and Distress). Refraining from catastrophic thinking may be negatively correlated with psychological distress due to its negative relation to repetitive negative thinking.

Enhancing the Personalization of Psychotherapy With Dynamic Assessment and Modeling

Clinicians have long recognized the importance of tailoring psychotherapy interventions to the needs and characteristics of the individual patient. However, traditional approaches to clinical assessment, service delivery, and intervention research have not been conducive to such personalization. Contrary to traditional nomothetic approaches, idiographic assessment and modeling of intraindividual dynamic processes holds tremendous promise for tailoring the implementation of psychotherapy to the individual patient. In this article, we (a) present an argument for assessing person-specific dynamics, (b) provide a detailed description of a method that harnesses person-specific dynamic assessment and modeling for use in routine psychotherapy, (c) present exemplar clinical cases illustrating these methods, and (d) discuss how these methods can be translated into routine clinical assessment and psychotherapy.

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT (ICBT) on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) to 16 March 2015. The CCDANCTR includes relevant randomised controlled trials from MEDLINE, EMBASE, PsycINFO and CENTRAL. We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate additional trials.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1736 citations and selected 38 studies (3214 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (5 trials), post-traumatic stress disorder (2 trials), obsessive compulsive disorder (2 trials), and specific phobia (2 trials). Eight remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (18 trials), Australia (14 trials), Switzerland (3 trials), the Netherlands (2 trials), and the USA (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, therapist-supported ICBT versus waiting list control, therapist-supported versus unguided ICBT, and therapist-supported ICBT versus face-to-face CBT.Low quality evidence from 11 studies (866 participants) contributed to a pooled risk ratio (RR) of 3.75 (95% CI 2.51 to 5.60; I(2) = 50%) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. The SMD for disorder-specific symptoms at post-treatment (28 studies, 2147 participants; SMD -1.06, 95% CI -1.29 to -0.82; I(2) = 83%) and general anxiety symptoms at post-treatment (19 studies, 1496 participants; SMD -0.75, 95% CI -0.98 to -0.52; I(2) = 78%) favoured therapist-supported ICBT; the quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (5 studies, 312 participants; SMD -0.22, 95% CI -0.56 to 0.13; I(2) = 58%; very low quality evidence) or general anxiety symptoms (2 studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; I(2) = 0%; very low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; I(2) = 0%; low quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (7 studies, 450 participants; SMD 0.06, 95% CI -0.25 to 0.37; I(2) = 60%; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; I(2) = 78%; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT were low quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should explore heterogeneity among studies which is reducing the quality of the evidence body, involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.

Rumination and Worry in Daily Life: Examining the Naturalistic Validity of Theoretical Constructs

Rumination and worry, two forms of perseverative thinking, hold promise as core processes that transect depressive and anxiety disorders. Whereas previous studies have been limited to the laboratory or to single diagnoses, we used experience sampling methods to assess and validate rumination and worry as transdiagnostic phenomena in the daily lives of individuals diagnosed with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and co-occurring MDD-GAD. Clinical and healthy control participants carried a hand-held electronic device for one week. Eight times per day they reported on their current levels of rumination and worry and their theoretically postulated features: thought unpleasantness, repetitiveness, abstractness, uncontrollability, temporal orientation, and content, and overall senses of certainty and control. Both rumination and worry emerged as transdiagnostic processes that cut across MDD, GAD, and MDD-GAD. Furthermore, most psychological theories concerning rumination and worry strongly mapped onto participants' reports, providing the first naturalistic validation of these constructs.

Mechanisms of change during group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder

Repetitive negative thinking (RNT) is a transdiagnostic process that serves to maintain emotional disorders. Metacognitive theory suggests that positive and negative metacognitive beliefs guide the selection of RNT as a coping strategy which, in turn, increases psychological distress. The aim of this study was to test the indirect effect of metacognitive beliefs on psychological distress via RNT. Patients (N=52) with primary and non-primary generalized anxiety disorder attended a brief, six-week group metacognitive therapy program and completed measures of metacognitive beliefs, RNT, and symptoms at the first and final treatment sessions, and at a one-month follow-up. Prospective indirect effects models found that negative metacognitive beliefs (but not positive metacognitive beliefs) had a significant indirect effect on psychological distress via RNT. As predicted by metacognitive theory, targeting negative metacognitions in treatment appears to reduce RNT and, in turn, emotional distress. Further research using alternative measures at multiple time points during therapy is required to determine whether the absence of a relationship with positive metacognitive beliefs in this study was a consequence of (a) psychometric issues, (b) these beliefs only being relevant to a subgroup of patients, or (c) a lack of awareness early in treatment.

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialized Register (CCDANCTR) to 12 April 2013. The CCDANCTR includes relevant randomised controlled trials from EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate further trials. An update of an initial search (April 2013), conducted in September 2014, identified seven new completed studies, seven previously ongoing studies now completed, and four new ongoing studies. This is a fast-moving area; we plan to update this review shortly, incorporating these new studies.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1000 citations and selected 30 studies (2181 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (4 trials), post-traumatic stress disorder (1 trial), and specific phobia (1 trial). Five remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (15 trials), Australia (12 trials), Switzerland (2 trials), and the Netherlands (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, experimental versus waiting list control, experimental versus unguided ICBT, and experimental versus face-to-face CBT.Moderate quality evidence from 9 studies (644 participants) contributed to a pooled RR of 4.18 (95% CI 2.42 to 7.22) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. Similarly, the SMD for disorder-specific symptoms at post-treatment (22 studies, 1573 participants; SMD -1.12, 95% CI -1.39 to -0.85) and general anxiety symptoms at post-treatment (14 studies, 1004 participants; SMD -0.79, 95% CI -1.10 to -0.48) favoured therapist-supported ICBT. The quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (4 studies, 253 participants; SMD -0.24, 95% CI -0.69 to 0.21; low quality evidence) or general anxiety symptoms (two studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; moderate quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (6 studies, 424 participants; SMD 0.09, 95% CI -0.26 to 0.43; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was low to very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT was low to moderate quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.