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

The economic burden of mental disorders: results from the Netherlands mental health survey and incidence study-2

OBJECTIVE

Currently, there is a paucity of up-to-date estimates of the economic burden caused by mental disorders. Such information could provide vital insight into one of the most serious and costly-yet to some extent preventable-health challenges facing the world today.

METHOD

Data from a national psychiatric-epidemiological cohort study (NEMESIS-2, N = 6506) were used to provide reliable, relevant, and up-to-date cost estimates (in 2019 Euro) regarding healthcare costs, productivity losses, and patient and family costs associated with DSM-IV mental disorders both at individual level, but also in the general population and in the workforce of the Netherlands (per 1 million population).

RESULTS

In the general population, the costs of mood disorders, specifically depression, are substantial and rank above those from the anxiety disorders, whilst costs of anxiety disorders are more substantial than those stemming from substance use disorders, even when the per-person costs of drug abuse appear highest of all. In the workforce, specific and social phobias are leading causes of excess costs. The workforce has lower healthcare costs but higher productivity costs than general population.

DISCUSSION

The findings suggest that (preventive) healthcare interventions targeting the workforce are likely to become cost-effective and underscore the importance for employers to create healthy work environments. Overall, the results highlight the need to strengthen the role of mental health promotion and prevention of mental disorders in the social domain before people require treatment to reduce the staggering and costly burden caused by mental disorders to individuals and society.

Improving usual care outcomes in major depression in youth by targeting memory specificity: A randomized controlled trial of adjunct computerized memory specificity training (c-MeST)

OBJECTIVE

Extending on previous findings that computerized Memory Specificity Training (c-MeST) improves memory specificity and depressive symptoms in Major Depressive Disorder (MDD) in adults, this study aimed to assess the effects of c-MeST in youth with MDD on memory specificity and depression in addition to other treatment.

METHODS

Participants aged 15-25 (N = 359, 76 % female; M age = 19.2, SD = 3.1), receiving predominantly psychological therapy or counseling (85 %) and/or antidepressants (52 %) were randomized to usual care and c-MeST or usual care. Cognitive and clinical outcomes were assessed at baseline and at one, three, and six-month follow-ups.

RESULTS

The usual care and c-MeST group reported higher memory specificity at one-month (d = 0.42, p = .022), but not at three or six months (d's < 0.15, p's > 0.05). The rate of MDE was numerically lower in the c-MeST group at each follow-up time-point, but group was not a statistically significant predictor at one month (64 % usual care and c-MeST vs. 68 % usual care, OR = 0.81, p = .606), three months (67 % usual care and c-MeST vs. 72 % usual care, OR = 0.64, p = .327) or six months (55 % usual care and c-MeST vs. 68 % usual care, OR = 0.56, p = .266). The usual care and c-MeST group did report lower depressive symptoms at one month (d = 0.42, p = .023) and six-months (d = 0.84, p = .001), but not three-months (d = 0.13, p > .05).

CONCLUSIONS

c-MeST may reduce symptoms in youth with MDD when provided alongside other treatments. However, there are significant limitations to this inference, including high attrition in the study and a need for more data on the acceptability of the intervention.

The relationship between wearable-derived sleep features and relapse in Major Depressive Disorder

BACKGROUND

Changes in sleep and circadian function are leading candidate markers for the detection of relapse in Major Depressive Disorder (MDD). Consumer-grade wearable devices may enable remote and real-time examination of dynamic changes in sleep. Fitbit data from individuals with recurrent MDD were used to describe the longitudinal effects of sleep duration, quality, and regularity on subsequent depression relapse and severity.

METHODS

Data were collected as part of a longitudinal observational mobile Health (mHealth) cohort study in people with recurrent MDD. Participants wore a Fitbit device and completed regular outcome assessments via email for a median follow-up of 541 days. We used multivariable regression models to test the effects of sleep features on depression outcomes. We considered respondents with at least one assessment of relapse (n = 218) or at least one assessment of depression severity (n = 393).

RESULTS

Increased intra-individual variability in total sleep time, greater sleep fragmentation, lower sleep efficiency, and more variable sleep midpoints were associated with worse depression outcomes. Adjusted Population Attributable Fractions suggested that an intervention to increase sleep consistency in adults with MDD could reduce the population risk for depression relapse by up to 22 %.

LIMITATIONS

Limitations include a potentially underpowered primary outcome due to the smaller number of relapses identified than expected.

CONCLUSION

Our study demonstrates a role for consumer-grade activity trackers in estimating relapse risk and depression severity in people with recurrent MDD. Variability in sleep duration and midpoint may be useful targets for stratified interventions.

Working mechanisms of the use and acceptability of ecological momentary interventions: a realist evaluation of a guided self-help ecological momentary intervention targeting self-esteem

BACKGROUND

Technology improves accessibility of psychological interventions for youth. An ecological momentary intervention (EMI) is a digital intervention geared toward intervening in daily life to enhance the generalizability and ecological validity, and to be able to intervene in moments most needed. Identifying working mechanisms of the use of ecological momentary interventions might generate insights to improve interventions.

METHODS

The present study investigates the working mechanisms of the use and acceptability of an ecological momentary intervention, named SELFIE, targeting self-esteem in youth exposed to childhood trauma, and evaluates under what circumstances these mechanisms of use and acceptability do or do not come into play. A realist evaluation approach was used for developing initial program theories (data: expert interviews and a stakeholders focus group), and subsequently testing (data: 15 interviews with participants, a focus group with therapists, debriefing questionnaire), and refining them.

RESULTS

The SELFIE intervention is offered through a smartphone application enabling constant availability of the intervention and thereby increasing accessibility and feasibility. When the intervention was offered on their personal smartphone, this enhanced a sense of privacy and less hesitance in engaging with the app, leading to increased disclosure and active participation. Further, the smartphone application facilitates the practice of skills in daily life, supporting the repeated practice of exercises in different situations leading to the generalizability of the effect. Buffering against technical malfunction seemed important to decrease its possible negative effects.

CONCLUSIONS

This study enhanced our understanding of possible working mechanisms in EMIs, such as the constant availability supporting increased accessibility and feasibility, for which the use of the personal smartphone was experienced as a facilitating context. Hereby, the current study contributes to relatively limited research in this field. For the field to move forward, mechanisms of use, and acceptability of EMIs need to be understood. It is strongly recommended that alongside efficacy trials of an EMI on specific target mechanisms, a process evaluation is conducted investigating the working mechanisms of use.

TRIAL REGISTRATION

The current paper reports on a realist evaluation within the SELFIE trial (Netherlands Trial Register NL7129 (NTR7475)).

No pain, no gain revisited: the impact of positive and negative psychotherapy experiences on treatment outcome

Objective

Psychotherapy may have many benefits for patients with mental health problems, but patients may also have negative experiences related to the therapy. Not much is known about these negative psychotherapy experiences and their impact on treatment outcome. The aim of this study was to examine the association between positive and negative psychotherapy experiences and treatment outcome.

Methods

A total of 130 patients participated in the study. They received treatment as usual and were assessed for positive and negative psychotherapy experiences at mid-treatment and post-treatment using the Positive and Negative Experiences of Psychotherapy Questionnaire (PNEP). Treatment outcome was measured by the Outcome Questionnaire - 45 (OQ-45). Multiple linear regression was used to analyze the data.

Results

All patients reported positive psychotherapy experiences at mid-treatment. At least one negative experience was reported by 69% of participants. After correction for baseline severity (i.e., OQ-45 at baseline) and relevant demographic variables, positive psychotherapy experiences at mid-treatment emerged as a predictor for treatment outcome. In contrast, negative psychotherapy experiences did not predict treatment outcome. However, reporting more negative experiences was associated with reporting fewer positive experiences at mid- and end of treatment.

Conclusion

Both positive and negative psychotherapy experiences commonly occur. Although in this study negative psychotherapy experiences did not predict treatment outcome in terms of symptom reduction, the findings do suggest that negative experiences may influence the way in which patients evaluate their treatment. Although positive experiences outweigh negative experiences, patients should be informed that negative experiences may also occur.

The future of psychological treatments: The Marburg Declaration

Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.

Evaluation of completely online psychotherapy with app-support versus therapy as usual for clients with depression or anxiety disorder: A retrospective matched cohort study investigating the effectiveness, efficiency, client satisfaction, and costs

INTRODUCTION

Depressive and anxiety disorders are common mental disorders ranking among the leading causes of global disease burden. Not all clients currently benefit from therapy and clients are looking for modern ways of therapy. Online psychotherapy is a promising option for better meeting clients' needs. Recently, a new psychotherapy concept has emerged that combines videoconferencing sessions with support through a mobile application. The latter allows for ecological momentary assessments and interventions, facilitates communication between patients and therapists in between sessions through chat, and allows for incorporating feedback-informed treatment principles.

MATERIAL AND METHODS

The study was a retrospective observational matched cohort study, comparing online psychotherapy with Therapy As Usual (TAU) for clients with depressive or anxiety disorders. Data were obtained via questionnaires, which are part of standard clinical care. Primary outcomes included general mental functioning, and symptoms of depression and anxiety. Secondary outcomes were efficiency, client satisfaction, and therapy costs. Primary endpoints were analyzed using linear mixed models analysis, with an interaction term between time and group. Secondary outcomes were analyzed using linear regression.

RESULTS

Larger improvements were observed in the online compared to the TAU group for general mental functioning and depressive disorder (i.e., General mental functioning: B = -8.50, 95 CI: -15.01 - -1.97, p = 0.011; Depressive disorder: B = - 3.66, 95 % CI: -5.79 - -1.54p < 0.01). No significant differences in change over time between the two groups were observed for anxiety disorder (B = -3.64, 95 % CI: (-13.10 - 5.82) p = 0.447). The total number of sessions was significantly higher in the online psychotherapy group than in TAU (B = 3.71, p < 0.01), although clients were matched on treatment time in weeks. Treatment session duration in minutes was comparable across the groups.

DISCUSSION

Online psychotherapy with app support showed to be a promising alternative to TAU for depressive and anxiety disorders. More research is needed to evaluate the effectiveness, cost-effectiveness and client satisfaction of online psychotherapy compared to TAU, such as randomized controlled trials or studies multiple baseline series designs, and in-depth qualitative research.

A framework for a brain-derived nosology of psychiatric disorders

Current psychiatric diagnoses are not defined by neurobiological measures which hinders the development of therapies targeting mechanisms underlying mental illness 1,2 . Research confined to diagnostic boundaries yields heterogeneous biological results, whereas transdiagnostic studies often investigate individual symptoms in isolation. There is currently no paradigm available to comprehensively investigate the relationship between different clinical symptoms, individual disorders, and the underlying neurobiological mechanisms. Here, we propose a framework that groups clinical symptoms derived from ICD-10/DSM-V according to shared brain mechanisms defined by brain structure, function, and connectivity. The reassembly of existing ICD-10/DSM-5 symptoms reveal six cross-diagnostic psychopathology scores related to mania symptoms, depressive symptoms, anxiety symptoms, stress symptoms, eating pathology, and fear symptoms. They were consistently associated with multimodal neuroimaging components in the training sample of young adults aged 23, the independent test sample aged 23, participants aged 14 and 19 years, and in psychiatric patients. The identification of symptom groups of mental illness robustly defined by precisely characterized brain mechanisms enables the development of a psychiatric nosology based upon quantifiable neurobiological measures. As the identified symptom groups align well with existing diagnostic categories, our framework is directly applicable to clinical research and patient care.

Treatment condition as a moderator and change in trait mindfulness as a mediator of a brief mindfulness ecological momentary intervention for generalized anxiety disorder

BACKGROUND

Theories propose that judgment of and reactivity to inner experiences are mediators of the effect of mindfulness-based interventions on generalized anxiety disorder (GAD). However, no study has tested such theories using brief, mindfulness ecological momentary intervention (MEMI). We thus tested these theories using a 14-day MEMI versus self-monitoring app (SM) control for GAD.

METHODS

Participants (N = 110) completed self-reports of trait mindfulness (Five Facet Mindfulness Questionnaire), GAD severity (GAD-Questionnaire-IV), and trait perseverative cognitions (Perseverative Cognitions Questionnaire) at prerandomization, posttreatment, and 1-month follow-up (1MFU). Counterfactual mediation analyses with temporal precedence were conducted.

RESULTS

Improvement in pre-post mindfulness domains (acceptance of emotions, describing feelings accurately, acting with awareness, judgment of inner experience, and reactivity to inner experience) predicted pre-1MFU reduction in GAD severity and pre-1MFU reduction in trait perseverative cognitions from MEMI but not SM. MEMI reduced pre-post reactivity to inner experiences (but not other mindfulness domains) significantly more than SM. Only reduced pre-post reactivity significantly mediated stronger efficacy of MEMI over SM on pre-1MFU reductions in GAD severity (indirect effect: β = -2.970 [-5.034, -0.904], p = .008; b path: β = -3.313 [-6.350, -0.276], p = .033; percentage mediated: 30.5%) and trait perseverative cognitions (indirect effect: β = -0.153 [-0.254, -0.044], p = .008; b path: β = -0.145 [-0.260, -0.030], p = .014; percentage mediated: 42.7%). Other trait mindfulness domains were non-significant mediators.

CONCLUSIONS

Reactivity to inner experience might be a mindfulness-based intervention change mechanism and should be targeted to optimize brief MEMIs for GAD.

You're not alone: imagery rescripting for adolescents who self-harm

Introduction

Non-suicidal self-injury (NSSI), which refers to the deliberate act of causing harm to one's own body without the intent to commit suicide, occurs in 20% of youth. Interestingly, approximately 90% of individuals who engage in self-harm report intrusive mental imagery thereof shortly prior to the act of NSSI. Previous research has demonstrated that imagery rescripting (IR) is an effective technique to treat intrusive mental images and associated clinical symptoms, such as emotion dysregulation, in various psychiatric disorders. However, there is no research on IR for adolescents who self-harm. Therefore, the present study aims to investigate the efficacy and feasibility of a two-session short-intervention using IR to reduce NSSI and associated clinical symptoms in adolescents. The intervention was supported by an app-based digital health intervention (DHI).

Methods

A single case series A-B design with three post-assessments (1 week, 1 month, and 3 months post-intervention) was implemented. Seven adolescents received two treatment sessions of IR, supported by a DHI between sessions. NSSI (SITBI), emotion regulation (ERQ), emotional distress (BDI-II, STAI-T), self-efficacy (WIRKALL_r), and treatment satisfaction (BIKEP) were evaluated.

Results

There was an increase in adaptive emotion regulation strategies up to 3 months post-intervention. Furthermore, patients improved regarding their self-efficacy, depressiveness, anxiety, and NSSI symptomatology. The developed DHI was described as a helpful and supportive tool.

Conclusion

The intervention has shown initial evidence to be feasible and beneficial for adolescents conducting NSSI. The DHI has demonstrated to be a valuable tool in the treatment of self-harming youth.

Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial

BACKGROUND

Virtual reality (VR) interventions, based on cognitive behavioral therapy principles, have been proven effective as complementary tools in managing obesity and have been associated with promoting healthy behaviors and addressing body image concerns. However, they have not fully addressed certain underlying causes of obesity, such as a lack of motivation to change, low self-efficacy, and the impact of weight stigma interiorization, which often impede treatment adherence and long-term lifestyle habit changes. To tackle these concerns, this study introduces the VR self-counseling paradigm, which incorporates embodiment and body-swapping techniques, along with motivational strategies, to help people living with obesity effectively address some of the root causes of their condition.

OBJECTIVE

This study aims to assess the clinical efficacy of ConVRself (Virtual Reality self-talk), a VR platform that allows participants to engage in motivational self-conversations.

METHODS

A randomized controlled trial was conducted with 68 participants from the bariatric surgery waiting list from the obesity unit of the Vall d'Hebron University Hospital in Barcelona, Spain. Participants were assigned to 1 of 3 groups: a control group (CG), which only received treatment as usual from the obesity unit; experimental group 1 (EG1), which, after intensive motivational interviewing training, engaged in 4 sessions of VR-based self-conversations with ConVRself, and underwent embodiment and body-swapping techniques; and experimental group 2 (EG2), which engaged in 4 VR-based sessions led by a virtual counselor with a prerecorded discourse, and only underwent the embodiment technique. In the case of both EG1 and EG2, the VR interventions were assisted by a clinical researcher. Readiness to change habits, eating habits, and psychological variables, as well as adherence and satisfaction with ConVRself were measured at baseline, after the intervention, 1 week after the intervention, and 4 weeks after the intervention.

RESULTS

Regarding the primary outcomes, EG1 (24/68, 35%) and EG2 (22/68, 32%) showed significant improvements in confidence to lose weight compared to the CG (22/68, 32%) at all assessment points (β=-.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG (β=-.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating (β=.71; P=.01) and emotional eating (β=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants (β=.65; P=.01). In addition, participants from the experimental groups reported high adherence and satisfaction with the VR platform (EG1: mean 59.82, SD 4.00; EG2: mean 58.43, SD 5.22; d=0.30, 95% CI -0.30 to 0.89).

CONCLUSIONS

This study revealed that using VR self-conversations, based on motivational interviewing principles, may have benefits in helping people with obesity to enhance their readiness to change habits and self-efficacy, as well as reduce dysfunctional eating behaviors and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05094557; https://www.clinicaltrials.gov/study/NCT05094557.

Comparing psychological versus pharmacological treatment in emotional disorders: A network analysis

Transdiagnostic group cognitive behavioural therapy (TD-GCBT) is more effective in improving symptoms and severity of emotional disorders (EDs) than treatment as usual (TAU; usually pharmacological treatment). However, there is little research that has examined the effects of these treatments on specific symptoms. This study used Network Intervention Analysis (NIA) to investigate the direct and differential effects of TD-GCBT + TAU and TAU on specific symptoms of anxiety and depression. Data are from a multicentre randomised clinical trial (N = 1061) comparing TD-GCBT + TAU versus TAU alone for EDs. The networks included items from the PHQ-9 (depression) and GAD-7 (anxiety) questionnaire and mixed graphical models were estimated at pre-treatment, post-treatment and 3-, 6- and 12-month follow-up. Results revealed that TD-GCBT + TAU was associated with direct effects, mainly on several anxiety symptoms and depressed mood after treatment. New direct effects on other depressive symptoms emerged during the follow-up period promoted by TD-GCBT compared to TAU. Our results suggest that the improvement of anxiety symptoms after treatment might precipitate a wave of changes that favour a decrease in depressive symptomatology. NIA is a methodology that can provide fine-grained insight into the likely pathways through which treatments exert their effects.

Traumatic stress, active engagement and resilience in first responders and civilians in the outbreak of war

Background: The outbreak of war in Israel on 7 October and the unique events of that day have presented unprecedented challenges to first responders (FRs), who are professionally trained to engage in providing assistance in such circumstances. Moreover, while research demonstrates the long-term psychological consequences of FRs, little is known regarding how FR's engagement in providing assistance relates to stress and resilience levels as events continue to unfold.Objective: The current study examined the relationship between traumatic stress symptoms (TSS) and resilience levels among FRs and controls during the first weeks of the Iron Swords war, while focusing on the moderating role of active engagement in providing assistance.Method: Data were collected during the first month of the Iron Swords war from 374 participants living in Southern Israel, of whom 77 (20.6%) were FRs. All participants filled out scales assessing TSS and resilience and provided relevant background information.Results: High TSS levels were associated with reduced resilience in FRs and non-FRs. Moreover, both the study group and active engagement were significant moderators for the TSS-resilience link, which was insignificant among FRs who provided assistance and for civilians who did not provide assistance. However, the TSS-resilience association remained significant for FRs who did not engage in providing assistance and for civilians who did.Conclusions: Our findings highlight the importance of examining the extent to which FRs act in line with their duties during times of adverse stress. Clinical interventions aimed towards FRs who did not engage in providing assistance are needed and should focus on the extent to which their moral values, beliefs and expectations are met, as these appear critical parameters in preserving resilience.

Psychological interventions for depression in children and adolescents: A bibliometric analysis

BACKGROUND

Depression has gradually become a common psychological disorder among children and adolescents. Depression in children and adolescents affects their physical and mental development. Psychotherapy is considered to be one of the main treatment options for depressed children and adolescents. However, our understanding of the global performance and progress of psychological interventions for depression in children and adolescents (PIDCA) research is limited.

AIM

To identify collaborative research networks in this field and explore the current research status and hotspots through bibliometrics.

METHODS

Articles and reviews related to PIDCA from January 2010 to April 2023 were identified from the Web of Science Core Collection database. The Charticulator website, CiteSpace and VOSviewer software were used to visualize the trends in publications and citations, the collaborative research networks (countries, institutions, and authors), and the current research status and hotspots.

RESULTS

Until April 16, 2023, 1482 publications were identified. The number of documents published each year and citations had increased rapidly in this field. The United States had the highest productivity in this field. The most prolific institution was the University of London. Pim Cuijpers was the most prolific author. In the context of research related to PIDCA, both reference co-citation analysis and keywords co-occurrence analysis identified 10 research hotspots, including third-wave cognitive behavior therapy, short-term psychoanalytic psychotherapy, cognitive behavioral analysis system of psychotherapy, family element in psychotherapy, modular treatment, mobile-health, emotion-regulation-based transdiagnostic intervention program, dementia risk in later life, predictors of the efficacy of psychological intervention, and risks of psychological intervention.

CONCLUSION

This bibliometric study provides a comprehensive overview of PIDCA from 2010 to present. Psychological intervention characterized as psychological-process-focused, short, family-involved, modular, internet-based, emotion-regulation-based, and personalized may benefit more young people.

Association between resting-state connectivity patterns in the defensive system network and treatment response in spider phobia-a replication approach

Although highly effective on average, exposure-based treatments do not work equally well for all patients with anxiety disorders. The identification of pre-treatment response-predicting patient characteristics may enable patient stratification. Preliminary research highlights the relevance of inhibitory fronto-limbic networks as such. We aimed to identify pre-treatment neural signatures differing between exposure treatment responders and non-responders in spider phobia and to validate results through rigorous replication. Data of a bi-centric intervention study comprised clinical phenotyping and pre-treatment resting-state functional connectivity (rsFC) data of n = 79 patients with spider phobia (discovery sample) and n = 69 patients (replication sample). RsFC data analyses were accomplished using the Matlab-based CONN-toolbox with harmonized analyses protocols at both sites. Treatment response was defined by a reduction of >30% symptom severity from pre- to post-treatment (Spider Phobia Questionnaire Score, primary outcome). Secondary outcome was defined by a reduction of >50% in a Behavioral Avoidance Test (BAT). Mean within-session fear reduction functioned as a process measure for exposure. Compared to non-responders and pre-treatment, results in the discovery sample seemed to indicate that responders exhibited stronger negative connectivity between frontal and limbic structures and were characterized by heightened connectivity between the amygdala and ventral visual pathway regions. Patients exhibiting high within-session fear reduction showed stronger excitatory connectivity within the prefrontal cortex than patients with low within-session fear reduction. Whereas these results could be replicated by another team using the same data (cross-team replication), cross-site replication of the discovery sample findings in the independent replication sample was unsuccessful. Results seem to support negative fronto-limbic connectivity as promising ingredient to enhance response rates in specific phobia but lack sufficient replication. Further research is needed to obtain a valid basis for clinical decision-making and the development of individually tailored treatment options. Notably, future studies should regularly include replication approaches in their protocols.

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Social pathways to care: how community-based network ties shape the health care response of individuals with mental health problems

PURPOSE

Mental health research has powerfully documented inequities related to characteristics, such as ethnicity and gender. Yet how and where disparities like unmet need occur have been more elusive. Drawing from a now modest body of research that deployed the Network Episode Model (NEM), we examine how individuals create patterns of response to mental health problems, influenced by the culture and resources embedded in their social networks.

METHODS

The Person-to-Person Health Interview Study (P2P; N ~ 2,700, 2018-2021) provides representative, community-based, NEM-tailored data. Both descriptive, latent class and multinomial regression analyses mark mental health care-seeking patterns, including individuals consulted and activities used, as well as the influence of the structure and cultural content of social networks.

RESULTS

Latent class analysis detected five pathways with good fit statistics. The Networked General Care Path (37.0%) and The Kin General Care Path (14.5%) differ only in whether friends are activated in using the general care sector. The Networked Multi-Sector Care Path (32.5%) and The Saturated Path (12.6%) involve family, friends, and both general and specialty care with only the latter expanding consultation to coworkers and clergy. The Null Path (3.3%), or no contacts, is not used as perceived problem severity increases. Network size and strength are associated with the more complex pathways that activate ties, respectively. Trust in doctors is associated with pathways that include specialty providers but not others at work or church. Race, age, and rural residence have specific pathway effects, while gender has no significant impact.

CONCLUSIONS

Social networks propel individuals with mental health problems into action. Tie strength and trust produce care responses that are fuller and more targeted. Considering the nature of homophily, results also suggest that majority status and college education are clearly implicated in networked pathways. Overall, findings support community-targeted rather than individually based efforts to increase service use.

A collaborative realist review of remote measurement technologies for depression in young people

Digital mental health is becoming increasingly common. This includes use of smartphones and wearables to collect data in real time during day-to-day life (remote measurement technologies, RMT). Such data could capture changes relevant to depression for use in objective screening, symptom management and relapse prevention. This approach may be particularly accessible to young people of today as the smartphone generation. However, there is limited research on how such a complex intervention would work in the real world. We conducted a collaborative realist review of RMT for depression in young people. Here we describe how, why, for whom and in what contexts RMT appear to work or not work for depression in young people and make recommendations for future research and practice. Ethical, data protection and methodological issues need to be resolved and standardized; without this, RMT may be currently best used for self-monitoring and feedback to the healthcare professional where possible, to increase emotional self-awareness, enhance the therapeutic relationship and monitor the effectiveness of other interventions.

Understanding mechanisms of depression prevention: study protocol of a randomized cross-over trial to investigate mechanisms of mindfulness and positive fantasizing as intervention techniques for reducing perseverative cognition in remitted depressed individuals

BACKGROUND

Major Depressive Disorder (MDD) is one of the most prevalent psychiatric disorders, and involves high relapse rates in which persistent negative thinking and rumination (i.e., perseverative cognition [PC]) play an important role. Positive fantasizing and mindfulness are common evidence-based psychological interventions that have been shown to effectively reduce PC and subsequent depressive relapse. How the interventions cause changes in PC over time, is unknown, but likely differ between the two. Whereas fantasizing may change the valence of thought content, mindfulness may operate through disengaging from automatic thought patterns. Comparing mechanisms of both interventions in a clinical sample and a non-clinical sample can give insight into the effectivity of interventions for different individuals. The current study aims to 1) test whether momentary psychological and psychophysiological indices of PC are differentially affected by positive fantasizing versus mindfulness-based interventions, 2) test whether the mechanisms of change by which fantasizing and mindfulness affect PC differ between remitted MDD versus never-depressed (ND) individuals, and 3) explore potential moderators of the main effects of the two interventions (i.e., what works for whom).

METHODS

In this cross-over trial of fantasizing versus mindfulness interventions, we will include 50 remitted MDD and 50 ND individuals. Before the start of the measurements, participants complete several individual characteristics. Daily-life diary measures of thoughts and feelings (using an experience sampling method), behavioural measures of spontaneous thoughts (using the Sustained Attention to Response Task), actigraphy, physiological measures (impedance cardiography, electrocardiography, and electroencephalogram), and measures of depressive mood (self-report questionnaires) are performed during the week before (pre-) the interventions and the week during (peri-) the interventions. After a wash-out of at least one month, pre- and peri-intervention measures for the second intervention are repeated.

DISCUSSION

This is the first study integrating self-reports, behavioural-, and physiological measures capturing dynamics at multiple time scales to examine the differential mechanisms of change in PC by psychological interventions in individuals remitted from multiple MDD episodes and ND individuals. Unravelling how therapeutic techniques affect PC in remitted individuals might generate insights that allows development of personalised targeted relapse prevention interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06145984, November 16, 2023.

Four Steps To My Future (4STMF): acceptability, feasibility and exploratory outcomes of a universal school-based mental health and well-being programme, delivered to young adolescents in South Africa

OBJECTIVE

Mental health disorders affect many children in South Africa, where vulnerability is high, and treatment is limited. We sought to determine the feasibility and acceptability of a universally delivered classroom-based programme for the promotion of mental health in young adolescents.

METHOD

We pilot tested an 8 session, cognitive-behavioural therapy-based programme, 4 Steps To My Future (4STMF) in two schools. Participants were grade 5 learners (n = 222; Meanage  = 10.62 (Standard deviation = 0.69)). 4STMF was delivered in class time by trained psychology postgraduates. Feasibility (rates of parental opt-out, child assent, assessment completion at baseline and follow-up, programme completion, session attendance and programme fidelity), acceptability (teacher feedback and focus groups with learners), as well as demographic data and data on a battery of a psychological measures were collected at baseline, postintervention and at one-month follow-up.

RESULTS

Most eligible learners at both schools agreed to participate (85% - school 1; 91% - school 2) with more than 80% completing postintervention measures. Learner session attendance and programme fidelity were high. Teachers rated facilitators highly on confidence, preparedness, enthusiasm and classroom management and observed children to be enjoying the programme. Focus group data suggest that learners liked the programme, could recall the content and had shared some of the content with their family. An exploratory analysis of outcomes showed significant pre-post differences on self-esteem at school 1 and on emotion regulation at school 1 and school 2, maintained at follow-up.

CONCLUSIONS

This pilot study has shown that 4STMF can acceptably and feasibly be delivered, at classroom level, as a universal school-based prevention programme to young adolescent learners in South African primary schools. The programme could fit in with school context, could be delivered by nonspecialists, showed significant improvements on self-esteem and emotion regulation and was liked by the learners.

Psychometric properties of the Persian version of the cognitive emotion regulation questionnaire-short (CERQ-P-short): Reliability, validity, factor structure, treatment sensitivity, and measurement invariance

AIMS

This study aimed to examine the psychometric properties of a widely-used measure of emotion regulation, the short version of the Cognitive Emotion Regulation Questionnaire (CERQ-short), in the Persian language (CERQ-P-short) among Iranian populations.

METHODS

The CERQ-P-short was administered to 1825 participants (female = 974) including 436 adolescents, 834 adults from the general population, 45 patients each with generalized anxiety and obsessive-compulsive disorders, an additional 30 patients each with generalized anxiety and obsessive-compulsive disorders receiving treatment, 45 patients with substance use disorders (SUDs) and an additional 360 adult psychiatric patients. We tested reliability, factor structure, measurement invariance, convergent and discriminant validity, and treatment sensitivity (i.e., intervention response) by age, sex, and diagnostic group. The Depression Anxiety Stress Scale-21 was also administered.

RESULTS

Cronbach's alpha coefficient and test-retest coefficients suggested good reliability. Fit indices suggested that the 9-factor CERQ-P-Short model was good across groups. The CERQ-P-Short showed good measurement invariance in all four models (configural, metric, scalar, and strict) in all groups. Both adaptive and maladaptive cognitive emotion-regulation strategies demonstrated convergent and discriminant validity. Finally, treatment sensitivity of the CERQ-P-Short scale before and after the completion of treatment sessions was suggested for patients with generalized anxiety and obsessive-compulsive disorders.

CONCLUSIONS

While the present study has some limitations, it represents a significant contribution because it supports CERQ-P-Short scales usefulness, validity, and reliability in the general population and among psychiatric patients. The results of the current study can be beneficial to the both clinicians and researchers.

Assessing Anxiety-Related Impairment in Children and Adolescents

Anxiety disorders (ADs) frequently lead to significant impairment across important domains of youth functioning. Yet until recently, clinical research and assessment have largely neglected the measurement of anxiety-related impairment. In this article, we review the evidence for five extant rating scales of youth anxiety-related impairment, guided by widely used evaluative criteria. Emerging psychometric data show the potential utility of these rating scales for achieving different assessment functions. Of the five scales, the Child Anxiety Impact Scale, particularly the parent-report version, has been the most researched one. Promising psychometric data support its use for assessing anxiety-related impairment in school, social, and family/home domains of functioning. We conclude with recommendations for growing this research base and for incorporating these rating scales into the youth AD clinical and research assessment process.

PsyNBIOsis: Investigating the Association between Maternal Gestational Diabetes, Mental Health, Diet and Childhood Obesity Risk: Protocol for a Prospective, Longitudinal, Observational Study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with poorer maternal mental health (depression and anxiety). Maternal mental health and GDM are likely to influence diet, which in turn impacts the course of GDM. Maternal diet may also be directly or indirectly associated with changes in infant anthropometry. The aims of this study are to (1) examine the associations between maternal GDM, mental health and diet, and (2) evaluate the associations between these maternal factors, breastmilk composition and infant anthropometry.

METHODS

This prospective, observational, longitudinal cohort study compares a cohort of women with and without GDM. Maternal mental health and diet are assessed using validated questionnaires. Breastmilk composition is measured with the Human Milk Analyzer, and infant body composition is measured with air displacement plethysmography.

SIGNIFICANCE AND IMPACT

Once data have been collected, PsyNBIOsis will provide evidence for the associations between maternal mental health, GDM status and diet, and their impact on breastmilk composition and early infant growth. The results may inform the Developmental Origins of Health and Disease framework and provide data on which to build cost-effective interventions to prevent both the development of mental health issues in mothers and adverse growth patterns in infants.

Acceptance and Commitment Therapy Among Informal Caregivers of People With Chronic Health Conditions: A Systematic Review and Meta-Analysis

Importance

Although there is substantial evidence to suggest the health benefits of acceptance and commitment therapy (ACT) among informal caregivers of people with chronic health conditions, the great variation in intervention designs among published studies limits its application.

Objectives

To identify intervention characteristics of ACT that are associated with improved psychological health and to assess the acceptability of ACT among informal caregivers.

Data Sources

Seven English- and 3 Chinese-language databases without limits on publication dates, the reference lists of previous reviews, and gray literature were searched up to February 2023.

Study Selection

Randomized clinical trials comparing the effect of ACT vs control groups on improving psychological health among informal caregivers.

Data Extraction and Synthesis

Two reviewers independently screened searched records and extracted data from eligible studies. Random-effects meta-analysis and mixed-effects metaregression were performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed.

Main Outcomes and Measures

Psychological health outcomes (eg, depressive symptoms) measured by valid measurements and the acceptability of ACT based on identified parameters.

Results

A total of 29 studies with 2010 participants, published between 2015 and 2023, were identified. ACT showed moderate to large effect sizes for improving psychological health at postintervention assessments (Hedges g range, -0.55 [95% CI, -0.98 to -0.12] to -1.14 [95% CI, -1.83 to -0.45]) and at 1-to-3-month and 4-to-6-month follow-ups (Hedges g range, -0.47 [95% CI, -0.69 to -0.25] to -1.29 [95% CI, -2.33 to -0.24]). Multivariable metaregression analysis regarding intervention characteristics found that ACT delivered in a mixed individual- and group-based format, face-to-face, or through more intervention sessions was associated with greater improvements for experiential avoidance (face-to-face: β = -1.170 [95% CI, -2.020 to -0.319]; number of sessions: β = -0.242 [95% CI, -0.353 to -0.130]), depressive symptoms (mixed delivery format: β = -2.583 [95% CI, -4.845 to -0.321]; face-to-face: β = -1.555 [95% CI, -3.002 to -0.108]), or anxiety symptoms (face-to-face: β = -1.241 [95% CI, -2.337 to -0.146]). In general, ACT had low attrition rates (11%), and participants' adherence (51%-80%) and satisfactory ratings (72%-95%) lend support to its acceptability.

Conclusions and Relevance

This systematic review and meta-analysis found that ACT was consistently associated with improvements in psychological health, supporting its application to improve informal care for chronic disease management. This review provides specific details on the design parameters of ACT for achieving greater efficacy.

What Do We Know About Depression Among Youth and How Can We Make Progress Toward Improved Understanding and Reducing Distress? A New Hope

This paper summarizes many findings about depression among children and adolescents. Depression is prevalent, highly distressing, and exerts considerable burden worldwide. Rates surge from childhood through young adulthood and have increased over the last decade. Many risk factors have been identified, and evidence-based interventions exist targeting mostly individual-level changes via psychological or pharmacological means. At the same time, the field appears stuck and has not achieved considerable progress in advancing scientific understanding of depression's features or delivering interventions to meet the challenge of youth depression's high and growing prevalence. This paper adopts several positions to address these challenges and move the field forward. First, we emphasize reinvigoration of construct validation approaches that may better characterize youth depression's phenomenological features and inform more valid and reliable assessments that can enhance scientific understanding and improve interventions for youth depression. To this end, history and philosophical principles affecting depression's conceptualization and measurement are considered. Second, we suggest expanding the range and targets of treatments and prevention efforts beyond current practice guidelines for evidence-based interventions. This broader suite of interventions includes structural- and system-level change focused at community and societal levels (e.g., evidence-based economic anti-poverty interventions) and personalized interventions with sufficient evidence base. We propose that by focusing on the FORCE (Fundamentals, Openness, Relationships, Constructs, Evidence), youth depression research can provide new hope.

Parity of esteem within the biopsychosocial model: is psychiatry still a psychological profession?

In recent years, the Royal College of Psychiatrists has been engaged in activities to ensure parity of esteem for mental health within the National Health Service, seeking to bring resources and services more in line with those available for physical health conditions. Central to this has been the promotion of psychiatry as a profession that takes a biopsychosocial approach, considering all aspects of the patient's presentation and history in the understanding and treatment of mental disorders. However, there has been a drift away from considering the psychological aspects of the patient's difficulties in recent years. This potentially has profoundly negative consequences for clinical care, training, workforce retention and the perception of our identity as psychiatrists by our colleagues, our patients and the general public. This editorial describes this issue, considers its causes and suggests potential remedies. It arises from an overarching strategy originating in the Royal College of Psychiatrists Medical Psychotherapy Faculty to ensure parity of esteem for the psychological within the biopsychosocial model.

[A Broader Scope - Bio-Psycho-Social Medicine In Global Focus]

Nach 1983 in Hamburg findet der ICPM-Weltkongress für Psychosomatische Medizin vom 19. bis 21. September 2024 zum zweiten Mal in Deutschland statt, und zwar in Tübingen. Der 27. Weltkongress des International College of Psychosomatic Medicine (ICPM) steht unter dem Motto „Advancing Psychosomatic Medicine in a Challenging World“. Der letzte ICPM-Kongress fand 2022 an der Wiege der bio-psycho-sozialen Medizin in Rochester, USA statt. Die dortige Abteilung, gegründet von George Engel – dem Begründer des biopsychosozialen Modells – und John Romano, feierte zugleich ihr 75-jähriges Jubiläum. Auch wir in Tübingen feiern einen runden Geburtstag – das 20-jährige Bestehen der neu gegründeten Abteilung für Psychosomatische Medizin und Psychotherapie an der Medizinischen Universitätsklinik – und wollen zu diesem Anlass insbesondere auch die einzigartige Entwicklung der Psychosomatischen Medizin und Psychotherapie in Deutschland mit ihren Stärken in Krankenversorgung, Forschung und Lehre aufzeigen (Hans-Christoph Friederich und Johannes Kruse).

The mental health toll of service: an examination of self-reported impacts of public safety personnel careers in a treatment-seeking population

Introduction: Public safety personnel (PSP), including firefighters, paramedics, and police officers, are exposed to traumatic events as part of their day-to-day jobs. These traumatic events often result in significant stress and increase the likelihood of negative mental health outcomes, including post-traumatic stress disorder (PTSD). The present study sought to develop an in-depth understanding of the lived experiences of PSPs as related to the mental health toll of their service. Through a series of targeted focus groups, Canadian PSP were asked to provide their perspectives on the PTSD-related symptoms that resulted as a by-product of their occupational service. The DSM-5-TR PSTD criteria (A-E) provided a thematic lens to map the self-described symptomatic expression of PSP's lived experiences.Methods: The present study employed a phenomenological focus-group approach with a treatment-seeking inpatient population of PSP. Participants included PSP from a variety of occupational backgrounds. Using semi-structured focus groups, fifty-one participants were interviewed. These focus groups were audio recorded, with consent, and transcribed verbatim. Using an interpretive phenomenological approach, emergent themes within the data were inductively developed, examined, and connected across individual cases.Results: Utilizing the primary criteria of PTSD (Criteria A-E) outlined by the DSM-5-TR, we identified qualitative themes that included exposure to a traumatic event, intrusion symptoms, avoidance symptoms, negative alterations in mood and cognition, and marked alterations in arousal and reactivity.Conclusion: PSP are exposed to extreme stressors as a daily part of their occupation and are at elevated risk of developing mental health difficulties, including PTSD. In the present study, focus groups were conducted with PSP about the mental health toll of their occupations. Their experiences mapped onto the five primary criteria of PTSD, as outlined by the DSM-5-TR. This study provides crucial descriptive information to guide mental health research aims and treatment goals for PSTD in PSP populations.

Demonstration of a 'leapfrog' randomized controlled trial as a method to accelerate the development and optimization of psychological interventions

BACKGROUND

The scale of the global mental health burden indicates the inadequacy not only of current treatment options, but also the pace of the standard treatment development process. The 'leapfrog' trial design is a newly-developed simple Bayesian adaptive trial design with potential to accelerate treatment development. A first leapfrog trial was conducted to provide a demonstration and test feasibility, applying the method to a low-intensity internet-delivered intervention targeting anhedonia.

METHODS

At the start of this online, single-blind leapfrog trial, participants self-reporting depression were randomized to an initial control arm comprising four weeks of weekly questionnaires, or one of two versions of a four-week cognitive training intervention, imagery cognitive bias modification (imagery CBM). Intervention arms were compared to control on an ongoing basis via sequential Bayesian analyses, based on a primary outcome of anhedonia at post-intervention. Results were used to eliminate and replace arms, or to promote them to become the control condition based on pre-specified Bayes factor and sample size thresholds. Two further intervention arms (variants of imagery CBM) were added into the trial as it progressed.

RESULTS

N = 188 participants were randomized across the five trial arms. The leapfrog methodology was successfully implemented to identify a 'winning' version of the imagery CBM, i.e. the version most successful in reducing anhedonia, following sequential elimination of the other arms.

CONCLUSIONS

The study demonstrates feasibility of the leapfrog design and provides a foundation for its adoption as a method to accelerate treatment development in mental health. Registration: clinicaltrials.gov, NCT04791137.

Experiences of Using Digital Mindfulness-Based Interventions: Rapid Scoping Review and Thematic Synthesis

BACKGROUND

Digital mindfulness-based interventions (MBIs) are a promising approach to deliver accessible and scalable mindfulness training and have been shown to improve a range of health outcomes. However, the success of digital MBIs is reliant on adequate engagement, which remains a crucial challenge. Understanding people's experiences of using digital MBIs and identifying the core factors that facilitate or act as barriers to engagement is essential to inform intervention development and maximize engagement and outcomes.

OBJECTIVE

This study aims to systematically map the literature on people's experiences of using digital MBIs that target psychosocial variables (eg, anxiety, depression, distress, and well-being) and identify key barriers to and facilitators of engagement.

METHODS

We conducted a scoping review to synthesize empirical qualitative research on people's experiences of using digital MBIs. We adopted a streamlined approach to ensure that the evidence could be incorporated into the early stages of intervention development. The search strategy identified articles with at least one keyword related to mindfulness, digital, user experience, and psychosocial variables in their title or abstract. Inclusion criteria specified that articles must have a qualitative component, report on participants' experiences of using a digital MBI designed to improve psychosocial variables, and have a sample age range that at least partially overlapped with 16 to 35 years. Qualitative data on user experience were charted and analyzed using inductive thematic synthesis to generate understandings that go beyond the content of the original studies. We used the Quality of Reporting Tool to critically appraise the included sources of evidence.

RESULTS

The search identified 530 studies, 22 (4.2%) of which met the inclusion criteria. Overall, the samples were approximately 78% female and 79% White; participants were aged between 16 and 69 years; and the most used measures in intervention studies were mindfulness, psychological flexibility, and variables related to mental health (including depression, anxiety, stress, and well-being). All studies were judged to be adequately reported. We identified 3 themes characterizing barriers to and facilitators of engagement: responses to own practice (ie, negative reactions to one's own practice are common and can deplete motivation), making mindfulness a habit (ie, creating a consistent training routine is essential yet challenging), and leaning on others (ie, those engaging depend on someone else for support).

CONCLUSIONS

The themes identified in this review provide crucial insights as to why people frequently stop engaging with digital MBIs. Researchers and developers should consider using person-based coparticipatory methods to improve acceptability of and engagement with digital MBIs, increase their effectiveness, and support their translation to real-world use. Such strategies must be grounded in relevant literature and meet the priorities and needs of the individuals who will use the interventions.

Best practice guidelines for citizen science in mental health research: systematic review and evidence synthesis

Partnering with people most affected by mental health problems can transform mental health outcomes. Citizen science as a research approach enables partnering with the public at a substantial scale, but there is scarce guidance on its use in mental health research. To develop best practise guidelines for conducting and reporting research, we conducted a systematic review of studies reporting mental health citizen science research. Documents were identified from electronic databases (n = 10), grey literature, conference proceedings, hand searching of specific journals and citation tracking. Document content was organised in NVIVO using the ten European Citizen Science Association (ECSA) citizen science principles. Best practise guidelines were developed by (a) identifying approaches specific to mental health research or where citizen science and mental health practises differ, (b) identifying relevant published reporting guidelines and methodologies already used in mental health research, and (c) identifying specific elements to include in reporting studies. A total of 14,063 documents were screened. Nine studies were included, from Australia, Belgium, Canada, Denmark, Netherlands, Spain, the UK, and the United States. Citizen scientists with lived experience of mental health problems were involved in data collection, analysis, project design, leadership, and dissemination of results. Most studies reported against some ECSA principles but reporting against these principles was often unclear and unstated. Best practise guidelines were developed, which identified mental health-specific issues relevant to citizen science, and reporting recommendations. These included citizen science as a mechanism for empowering people affected by mental health problems, attending to safeguarding issues such as health-related advice being shared between contributors, the use of existing health research reporting guidelines, evaluating the benefits for contributors and impact on researchers, explicit reporting of participation at each research stage, naming the citizen science platform and data repository, and clear reporting of consent processes, data ownership, and data sharing arrangements. We conclude that citizen science is feasible in mental health and can be complementary to other participatory approaches. It can contribute to active involvement, engagement, and knowledge production with the public. The proposed guidelines will support the quality of citizen science reporting.

Investigation of Active Ingredients Within Internet-Delivered Cognitive Behavioral Therapy for Depression: A Randomized Optimization Trial

Importance

There is limited understanding of how complex evidence-based psychological interventions such as cognitive behavioral therapy (CBT) for depression work. Identifying active ingredients may help to make therapy more potent, brief, and scalable.

Objective

To test the individual main effects and interactions of 7 treatment components within internet-delivered CBT for depression to investigate its active ingredients.

Design, Setting, and Participants

This randomized optimization trial using a 32-condition, balanced, fractional factorial optimization experiment (IMPROVE-2) recruited adults with depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) from internet advertising and the UK National Health Service Improving Access to Psychological Therapies service. Participants were randomized from July 7, 2015, to March 29, 2017, with follow-up for 6 months after treatment until December 29, 2017. Data were analyzed from July 2018 to April 2023.

Interventions

Participants were randomized with equal probability to 7 experimental factors within the internet CBT platform, each reflecting the presence vs absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, and self-compassion training).

Main Outcomes and Measures

The primary outcome was depression symptoms (PHQ-9 score). Secondary outcomes include anxiety symptoms and work, home, and social functioning.

Results

Among 767 participants (mean age [SD] age, 38.5 [11.62] years; range, 18-76 years; 635 women [82.8%]), 506 (66%) completed the 6-month posttreatment follow-up. On average, participants receiving internet-delivered CBT had reduced depression (pre-to-posttreatment difference in PHQ-9 score, -7.79 [90% CI, -8.21 to -7.37]; 6-month follow-up difference in PHQ-9 score, -8.63 [90% CI, -9.04 to -8.22]). A baseline score-adjusted analysis of covariance model using effect-coded intervention variables (-1 or +1) found no main effect on depression symptoms for the presence vs absence of activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, or self-compassion training (posttreatment: largest difference in PHQ-9 score [functional analysis], -0.09 [90% CI, -0.56 to 0.39]; 6-month follow-up: largest difference in PHQ-9 score [relaxation], -0.18 [90% CI, -0.61 to 0.25]). Only absorption training had a significant main effect on depressive symptoms at 6-month follow-up (posttreatment difference in PHQ-9 score, 0.21 [90% CI, -0.27 to 0.68]; 6-month follow-up difference in PHQ-9 score, -0.54, [90% CI, -0.97 to -0.11]).

Conclusions and Relevance

In this randomized optimization trial, all components of internet-delivered CBT except absorption training did not significantly reduce depression symptoms relative to their absence despite an overall average reduction in symptoms. The findings suggest that treatment benefit from internet-delivered CBT probably accrues from spontaneous remission, factors common to all CBT components (eg, structure, making active plans), and nonspecific therapy factors (eg, positive expectancy), with the possible exception of absorption focused on enhancing direct contact with positive reinforcers.

Trial Registration

isrctn.org Identifier: ISRCTN24117387.

Reducing intrusive memories after trauma via an imagery-competing task intervention in COVID-19 intensive care staff: a randomised controlled trial

Intrusive memories (IMs) after traumatic events can be distressing and disrupt mental health and functioning. We evaluated the impact of a brief remotely-delivered digital imagery-competing task intervention on the number of IMs for intensive care unit (ICU) staff who faced repeated trauma exposure during the COVID-19 pandemic using a two-arm, parallel-group, single-blind randomised controlled trial, with the comparator arm receiving delayed access to active treatment (crossover). Eligible participants worked clinically in a UK NHS ICU during the pandemic and had at least 3 IMs of work-related traumatic events in the week before recruitment. Participants were randomly assigned (1:1) to immediate (weeks 1-4) or delayed (weeks 5-8) intervention access. Sequential Bayesian analyses to optimise the intervention and increase trial efficiency are reported elsewhere [1]. The primary endpoint for the pre-specified frequentist analysis of the final study population compared the number of IMs experienced in week 4 between the immediate and delayed access arms. Secondary outcomes included clinical symptoms, work functioning and wellbeing. Safety was assessed throughout the trial by scheduled questions and free report. All analyses were undertaken on an intention-to-treat basis (86 randomised participants). There were significantly fewer intrusive memories during week 4 in the immediate (median = 1, IQR = 0-3, n = 43), compared to the comparator delayed arm (median = 10, IQR = 6-17, n = 43), IRR 0.31, 95% CI: 0.20-0.48, p < 0.001. After crossover, the delayed arm also showed a significant reduction in IMs at week 8 compared to week 4. There were convergent findings for symptoms of PTSD, insomnia and anxiety, work engagement and burnout, general functioning and quality of life. The intervention was found safe and acceptable to participants. All adverse events were unrelated to the study. Our study provides the first evidence of a benefit on reducing IMs, improving other clinical symptoms, work functioning and wellbeing, as well as safety of a brief remotely-delivered digital imagery-competing task intervention. An efficacy trial with an active control and longer follow-up is warranted. The trial is registered at ClinicalTrials.gov (NCT04992390).

Editorial: How Online Treatment Research Can Enrich Child and Adolescent Psychiatry

Evidence is accumulating that treatment for psychiatric problems can in some cases be effectively delivered online.1 Online treatment does not necessarily imply less therapist support (eg, treatment can be delivered through video call), but most online treatments are at least in part self-directed. Research on online treatment therefore not only answers to calls from policy makers and clinical practice about when online treatment can safely replace or outperform in-person treatment, but also challenges assumptions on hypothesized key therapeutic principles (eg, essential common elements) and can discover new therapeutic principles.

Feasibility and efficacy of a digital resilience training: A pilot study of the strengths-based training RESIST

Background

Work-related stress is a risk factor for a number of adverse health and work outcomes. Resilience trainings are a promising approach for adequately dealing with work stress and keeping employees mentally healthy. However, results of previous resilience trainings have been heterogeneous, ranging from null findings to large effects. Existing digital resilience interventions show a lack of consistency in terms of an underlying theoretical framework and methods used to foster resilience. Positive Appraisal Style Theory of Resilience offers an innovative conceptualization of resilience. Strengths-based cognitive behavioral therapy is a corresponding therapeutically method reflecting resilience as a resource-oriented process of dealing with stress. Based on this background, a new hybrid web-and app-based digital resilience intervention for employees named RESIST was developed.

Objective

The first aim of the study was to investigate the feasibility of the newly developed training RESIST regarding its usability, user behavior, user experience and motivation to use. Second, the study sought to explore preliminary effects of the intervention on reducing stress and enhancing resilience by conducting a pilot randomized controlled trial.

Methods

The feasibility study was conducted in three phases. First, the usability of the app was investigated in a pre-test with five participants using a thinking-aloud method. Second, the preliminary efficacy of the training was examined in a pilot randomized controlled trial. A sample of 30 employees were randomized either to receive the resilience training (n = 15) or to be member of a control group (n = 15). The primary outcome was measuring perceived stress. Secondary outcomes included measures of resilience and depressive symptoms. Third, semi-structured interviews were undertaken with six participants of the resilience training group on training content, motivation for use, and user experience.

Results

Overall, results indicate that RESIST can be a feasible training for resilience promotion and stress reduction with high user satisfaction. Analysis of covariance showed that, relative to controls, participants who received RESIST reported significantly lower stress scores at post-intervention (F1,27 = 16.91, p < 0.001; Cohen's d = 1.57; 95 % CI 0.71-2.43) than controls. Significant differences, with moderate-to-large effect sizes, were also detected for general resilience and various resilience factors.

Conclusions

Results are promising and provide hope that a hybrid web- and app-based resilience intervention based on strengths-based cognitive behavioral therapy can have a positive impact on dealing adequately with stress and improve resilience of employees.

Multidimensional Internet Use, Social Participation, and Depression Among Middle-Aged and Elderly Chinese Individuals: Nationwide Cross-Sectional Study

BACKGROUND

There is growing evidence that the internet has beneficial effects on the mental health of middle-aged and older people (≥45 years), but the evidence is inconclusive, and the underlying mechanisms are less known.

OBJECTIVE

This study aims to explore the relationship between multidimensional (devices, frequency, and purpose) internet use and depression in middle-aged and elderly Chinese, as well as the mediating effect of social participation. Moreover, this study will explore the moderating effect of the regional informatization development level (RIDL) on the relationships between individual internet use, social participation, and depression.

METHODS

Data on 17,676 participants aged 45 years or older were obtained from the China Health and Retirement Longitudinal Study (CHARLS) 2018 data set. The 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) was used to identify the presence of depression. Logistic regression was used to explore the relationship between each dimension of internet use and depression. Multiple linear regression was used to explore the mediating effect of social participation and the moderating effect of the RIDL.

RESULTS

The results showed that 28.33% (5008/17,676) of the total population had depression. In terms of regional subgroups, respondents living in the western region exhibited the highest proportion of depression (2041/5884, 34.69%). Internet use was negatively associated with depression (odds ratio 0.613, 95% CI 0.542-0.692; P<.001). Various dimensions of internet use positively contributed to individual social participation and reduced individual depression (devices: β=-.170, 95% CI -0.209 to -0.127; frequency: β=-.065, 95% CI -0.081 to -0.047; and purpose: β=-.043, 95% CI -0.053 to -0.031). In addition, the RIDL weakened the relationship between individual-level internet use and social participation (internet use: F74.12,9.82=7.55, P<.001; devices: F51.65/9.88=5.23, P=.005; frequency: F66.74/10.08=6.62, P=.001; and purpose: F66.52/9.78=6.80, P=.001), and negatively moderated the relationship between the frequency of internet use and depression (frequency: F662.67/188.79=3.51, P=.03).

CONCLUSIONS

This study found that different dimensions of internet use are associated with lower levels of depression. Social participation partially mediates the association between multidimensional internet use and depression in the eastern, central, and western regions, respectively. Additionally, the RIDL helps individuals further their internet use and social participation, reducing the impact of depression. However, this effect weakens sequentially from the western region to the central region and then to the eastern region.

The Ghent Psychotherapy Study: A Pragmatic, Stratified, Randomized Parallel Trial into the Differential Efficacy of Psychodynamic and Cognitive-Behavioral Interventions in Dependent and Self-Critical Depressive Patients

INTRODUCTION

Different types of psychotherapy are effective for treating major depressive disorder across groups yet show large within-group differences. Patient personality style is considered a potentially useful variable for treatment matching.

OBJECTIVE

This study is the first experimental test of the interaction between therapeutic approach and patients' dependent versus self-critical personality styles.

METHODS

A pragmatic stratified parallel trial was carried out with 100 adult patients diagnosed with DSM-IV-TR major depressive disorder. They were randomly assigned to short-term (16-20 sessions) cognitive behavioral therapy (CBT) or short-term psychodynamic psychotherapy (STPP). Patients were assessed at baseline, during therapy, post-therapy, and at 3- and 6-month follow-up. Primary outcome is depression severity measured by the Hamilton Rating Scale for Depression posttreatment. Primary analysis was by intention to treat. This trial is registered with the ISRCTN registry (www.isrctn.com), number ISRCTN17130982.

RESULTS

The intention-to-treat sample consisted of 100 participants; 40 with self-critical and 60 with dependent personality styles were randomized to either CBT (n = 50) or STPP (n = 50). We observed no interaction effect (-0.34 [-6.14, 5.46]) between therapy and personality style and found no evidence for a difference in effectiveness between the treatments in general in terms of symptom reduction and maintained benefits at 6-month follow-up.

CONCLUSION

We found no evidence that dependent versus self-critical personality styles moderate the relation between treatment and outcome in depression. Research using individual patient data could gain further insight into why specific therapeutic approaches work better for specific patients.

The effectiveness of social network interventions for psychiatric patients: A systematic review and meta-analysis

Strengthening social networks is an important goal in mental health treatment. This study aimed to determine the effectiveness of social network interventions for psychiatric patients. A systematic review and meta-analysis was conducted comparing these interventions with control groups on social and mental health-related outcomes in psychiatric patients. PubMed, EMBASE.com, PsycInfo, Scopus, and IBSS were searched for studies until December 21, 2022. Three-level random effects models were used to obtain Cohen's d mean estimates on composite outcomes of social network and secondary mental health outcomes. Heterogeneity was examined with potential moderators. Thirty-three studies were included. Small-to-moderate effects of social network interventions were detected on positive social network (d = 0.115, p = 0.022) and support (d = 0.159; p = 0.007), general functioning (d = 0.127, p = 0.046), mental health treatment adherence (d = 0.332, p = 0.003), days substance use (d = 0.097, p = 0.004), and abstinence (d = 0.254, p = 0.004). Estimates of psychiatric functioning were higher in samples with more females. The quality of evidence was moderate-to-low. This evidence suggests that social network interventions can improve positive social networks, general functioning, mental health treatment adherence, and substance use in psychiatric patients receiving usual care. PROSPERO ID: CRD42019131959.

Investigating the role of action-contingent expectancy biases in dysphoria-linked activity engagement behavioural choice

Reduced tendency to engage in potentially rewarding activities is a hallmark of depression. The present study investigated the role of future expectancy biases in depression-linked behavioural choice, in participants varying in self-reported depression symptoms (dysphoria). A novel laboratory paradigm was developed to test the hypotheses that the degree to which higher dysphoria is associated with reduced tendency to engage in a potentially rewarding activity is dependent on the presence of negative biases in the expected outcomes of activity engagement. Specifically, two types of expectancy biases were distinguished: a) the expected likelihood of a negative rather than positive outcome, and b) the expected emotional impact of either outcome. N = 176 undergraduate students with varied levels of dysphoria were given the opportunity to choose to engage in a coin-tossing game that could result in a win or loss monetary outcome in terms of charity donations, and then rated both types of expectancies. Results indicated that higher dysphoria was associated with more negative expectations concerning the likelihood of objective outcomes and the emotional impact of such outcomes, and as hypothesised, such negative expectancy biases mediated indirect associations between dysphoria and behavioural choice.

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

T-RAC: Study protocol of a randomised clinical trial for assessing the acceptability and preliminary efficacy of adding an exergame-augmented dynamic imagery intervention to the behavioural activation treatment of depression

BACKGROUND

Improving the existent effective treatments of depression is a promising way to optimise the effects of psychological treatments. Here we examine the effects of adding a rehabilitation type of imagery based on exergames and dynamic simulations to a short behavioural activation treatment of depression. We investigate the acceptability and the efficacy of an exergame-augmented dynamic imagery intervention added to behavioural activation treatment and associated mechanisms of change.

METHODS AND ANALYSES

In a two-arm pilot randomised controlled trial, the acceptability and preliminary efficacy of an exergame-augmented dynamic imagery intervention added to behavioural activation treatment for depressed individuals will be assessed. Participants (age 18-65) meeting criteria for depression are recruited by media and local announcements. 110 participants will be randomly allocated to behavioural activation plus imagery group or to standard behavioural activation group. The primary outcome is depressive symptom severity (Beck Depression Inventory II) and secondary outcomes are anhedonia, apathy and behavioural activation and avoidance. The outcomes are assessed at baseline, mid treatment, posttreatment and 3-month follow-up. Moderation and mediation analyses will be explored. An intention-to-treat approach with additional per-protocol analysis will be used for data analysis.

A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial

BACKGROUND

The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely.

OBJECTIVE

This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students.

METHODS

US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness.

RESULTS

Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated.

CONCLUSIONS

STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.

Review: Adverse event monitoring and reporting in studies of pediatric psychosocial interventions: a systematic review

BACKGROUND

Adverse event monitoring in studies of psychotherapy is crucial to clinical decision-making, particularly for weighing of benefits and harms of treatment approaches. In this systematic review, we identified how adverse events are defined, measured, and reported in studies of psychosocial interventions for children with mental disorders.

METHOD

Medline, PsycINFO, Embase, ProQuest Dissertations and Theses Global, and the Cochrane Library were searched from January 2011-January 2023, and Google Scholar from January 2011-February 2023. English language experimental and quasi-experimental studies that evaluated the efficacy or effectiveness of psychosocial interventions for childhood mental disorders were included. Information on the definition, assessment, and report of adverse events was extracted using a checklist based on Good Clinical Practice guidelines.

RESULTS

In this review, 117 studies were included. Studies most commonly involved treating anxiety disorders or obsessive-compulsive disorder (32/117; 27%); 44% of the experimental interventions tested (52/117) were cognitive behavioral therapies. Adverse events were monitored in 36 studies (36/117; 31%) with a protocol used in 19 of these studies to guide monitoring (19/36; 53%). Twenty-seven different events were monitored across the studies with hospitalization the most frequently monitored (3/36; 8%). Event severity was fully assessed in 6 studies (17%) and partially assessed in 12 studies (33%). Only 4/36 studies (11%) included assessing events for cause.

CONCLUSIONS

To date, adverse events have been inconsistently defined, measured and reported in psychosocial intervention studies of childhood mental health disorders. Information on adverse events is an essential knowledge component for understanding the potential impacts and risks of therapeutic interventions.

Effectiveness of and processes related to internet-delivered acceptance and commitment therapy for adolescents with anxiety disorders: a randomized controlled trial

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on theoretically derived and empirically tested key mechanisms in treatment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexibility and treatment outcomes and the relationship between participating adolescents' and therapists' perceived alliance and treatment outcomes. This was a randomized controlled trial comparing a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participating adolescents and therapists but showed no significant relationship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts.

Effect of Internet-Delivered Emotion Regulation Individual Therapy for Adolescents With Nonsuicidal Self-Injury Disorder: A Randomized Clinical Trial

Importance

Nonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking.

Objective

To test the hypotheses that an internet-delivered emotion regulation individual therapy for adolescents delivered adjunctive to treatment as usual is superior to treatment as usual only in reducing nonsuicidal self-injury and that improvements in emotion regulation mediate these treatment effects.

Design, Setting, and Participants

This 3-site, single-masked, randomized superiority trial enrolled participants from November 20, 2017, to April 9, 2020. Eligible participants were aged between 13 and 17 years and met diagnostic criteria for nonsuicidal self-injury disorder; they were enrolled as a mixed cohort of consecutive patients and volunteers. Parents participated in parallel to their children. The primary end point was at 1 month after treatment. Participants were followed up at 3 months posttreatment. Data collection ended in January 2021.

Interventions

Twelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only.

Main Outcomes and Measures

Primary outcome was the youth version of the Deliberate Self-harm Inventory, both self-reported by participants prior to treatment, once every week during treatment, and for 4 weeks posttreatment, and clinician-rated by masked assessors prior to treatment and at 1 and 3 months posttreatment.

Results

A total of 166 adolescents (mean [SD] age, 15.0 [1.2] years; 154 [92.8%] female) were randomized to internet-delivered emotion regulation therapy plus treatment as usual (84 participants) or treatment as usual only (82 participants). The experimental intervention was superior to the control condition in reducing clinician-rated nonsuicidal self-injury (82% vs 47% reduction; incidence rate ratio, 0.34; 95% CI, 0.20-0.57) from pretreatment to 1-month posttreatment. These results were maintained at 3-month posttreatment. Improvements in emotion dysregulation mediated improvements in self-injury during treatment.

Conclusions and Relevance

In this randomized clinical trial, a 12-week, therapist-guided, internet-delivered emotion regulation therapy delivered adjunctive to treatment as usual was efficacious in reducing self-injury, and mediation analysis supported the theorized role of emotion regulation as the mechanism of change in this treatment. This treatment may increase availability of evidence-based psychological treatments for adolescents with nonsuicidal self-injury.

Trial Registration

ClinicalTrials.gov Identifier: NCT03353961.

Treating intrusive memories after trauma in healthcare workers: a Bayesian adaptive randomised trial developing an imagery-competing task intervention

Intensive care unit (ICU) staff continue to face recurrent work-related traumatic events throughout the COVID-19 pandemic. Intrusive memories (IMs) of such traumatic events comprise sensory image-based memories. Harnessing research on preventing IMs with a novel behavioural intervention on the day of trauma, here we take critical next steps in developing this approach as a treatment for ICU staff who are already experiencing IMs days, weeks, or months post-trauma. To address the urgent need to develop novel mental health interventions, we used Bayesian statistical approaches to optimise a brief imagery-competing task intervention to reduce the number of IMs. We evaluated a digitised version of the intervention for remote, scalable delivery. We conducted a two-arm, parallel-group, randomised, adaptive Bayesian optimisation trial. Eligible participants worked clinically in a UK NHS ICU during the pandemic, experienced at least one work-related traumatic event, and at least three IMs in the week prior to recruitment. Participants were randomised to receive immediate or delayed (after 4 weeks) access to the intervention. Primary outcome was the number of IMs of trauma during week 4, controlling for baseline week. Analyses were conducted on an intention-to-treat basis as a between-group comparison. Prior to final analysis, sequential Bayesian analyses were conducted (n = 20, 23, 29, 37, 41, 45) to inform early stopping of the trial prior to the planned maximum recruitment (n = 150). Final analysis (n = 75) showed strong evidence for a positive treatment effect (Bayes factor, BF = 1.25 × 106): the immediate arm reported fewer IMs (median = 1, IQR = 0-3) than the delayed arm (median = 10, IQR = 6-16.5). With further digital enhancements, the intervention (n = 28) also showed a positive treatment effect (BF = 7.31). Sequential Bayesian analyses provided evidence for reducing IMs of work-related trauma for healthcare workers. This methodology also allowed us to rule out negative effects early, reduced the planned maximum sample size, and allowed evaluation of enhancements. Trial Registration NCT04992390 ( www.clinicaltrials.gov ).

Maternal reminiscing as critical to emotion socialization

Background

In the wake of the COVID-19 pandemic, the central importance of socioemotional skills in positive child development has become even more apparent. Prevalent models of emotion socialization emphasize the importance of parent-child talk as a critical socialization context.

Purpose

Autobiographical reminiscing about the child's lived experience may be a particularly effective form of parent-child conversation that facilitates emotion understanding.

Method

The authors provide a theoretical and empirical review of how maternal reminiscing style impacts specifically on emotion socialization in both typically and atypically developing children.

Results

Individual differences in maternal reminiscing indicate that highly elaborative reminiscing is related to both better narrative skills and higher levels of emotion understanding and regulation both concurrently and longitudinally. Intervention studies indicate that mothers can be coached to be more elaborative during reminiscing and coaching leads to higher levels of emotion understating and regulation.

Conclusions

Reminiscing about lived experience allows mothers and children to explore and examine emotions in personally meaningful situations that have real world implications for children's evolving emotion understanding.

Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial

BACKGROUND

Evidence-based mental health interventions to support healthcare workers (HCWs) in crisis settings are scarce.

OBJECTIVE

To evaluate the capacity of a mental health intervention in reducing anxiety and depression symptoms in HCWs, relative to enhanced care as usual (eCAU), amidst the COVID-19 pandemic.

METHODS

We conducted an analyst-blind, parallel, multicentre, randomised controlled trial. We recruited HCWs with psychological distress from Madrid and Catalonia (Spain). The intervention arm received a stepped-care programme consisting of two WHO-developed interventions adapted for HCWs: Doing What Matters in Times of Stress (DWM) and Problem Management Plus (PM+). Each intervention lasted 5 weeks and was delivered remotely by non-specialist mental health providers. HCWs reporting psychological distress after DWM completion were invited to continue to PM+. The primary endpoint was self-reported anxiety/depression symptoms (Patient Health Questionnaire-Anxiety and Depression Scale) at week 21.

FINDINGS

Between 3 November 2021 and 31 March 2022, 115 participants were randomised to stepped care and 117 to eCAU (86% women, mean age 37.5). The intervention showed a greater decrease in anxiety/depression symptoms compared with eCAU at the primary endpoint (baseline-adjusted difference 4.4, 95% CI 2.1 to 6.7; standardised effect size 0.8, 95% CI 0.4 to 1.2). No serious adverse events occurred.

CONCLUSIONS

Brief stepped-care psychological interventions reduce anxiety and depression during a period of stress among HCWs.

CLINICAL IMPLICATIONS

Our results can inform policies and actions to protect the mental health of HCWs during major health crises and are potentially rapidly replicable in other settings where workers are affected by global emergencies.

TRIAL REGISTRATION NUMBER

NCT04980326.