The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis

Digital Psychotherapies for Adults Experiencing Depressive Symptoms: Systematic Review and Meta-Analysis

BACKGROUND

Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives.

OBJECTIVE

This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients' and practitioners' perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression.

METHODS

A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients' and therapists' perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups.

RESULTS

Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included "stand-alone" or non-human contact interventions (58/160, 36.2%), "human contact" interventions (11/160, 6.8%), and "blended" including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=-0.61, 95% CI -0.75 to -0.47; Z=-8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=-0.793), while interventions involving human contact (Hedges g=-0.42) or no human contact (Hedges g=-0.40) had slightly smaller effect sizes.

CONCLUSIONS

Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics.

TRIAL REGISTRATION

PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=238462.

Clinical Considerations for Integrating Ethical Principles of Beneficence in the Development of Evidence-Based Interventions: The case of Pediatric Misophonia

Misophonia is a condition involving decreased tolerance and intense responses to specific sounds, often those that are human-generated and repetitive in nature. Misophonia frequently onsets during childhood and is associated with significant distress, impairment, and diminished quality of life. While misophonia research remains nascent and no definitive practice guidelines exist at present, extant studies offer several promising potential avenues in intervention development for adults with misophonia. However, such research is comparatively limited for youth. Before widespread adoption of promising treatments, it is important to consider the potential for harm or non-beneficence that may arise from the mis-informed application of such treatments. In this article, we identify several potential pitfalls within intervention development for pediatric misophonia and provide recommendations to circumvent them. To that end, we focus on the following three topic areas: (a) challenges arising when psychological mechanisms are not considered in intervention development, (b) importation of a cognitive-behavior therapy (CBT) framework for obsessive-compulsive spectrum disorders without nuanced tailoring to misophonia, and (c) neglecting to include individuals with lived experience in the process of intervention development research. Considering these key areas within misophonia intervention development will be critical for upholding beneficence and minimizing harm in treatment of misophonia across the lifespan.

A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.

Effectiveness of Behavioral and Pharmacologic Interventions for Depressive Symptoms After Spinal Cord Injury: Findings From a Systematic Review

OBJECTIVE

To summarize and evaluate evidence regarding the efficacy of interventions for depressive symptoms in adults living with spinal cord injury (SCI) and comorbid major depressive disorder or significant depressive symptoms to inform the development of clinical practice guidelines.

DATA SOURCES

Articles published since 2013 and available in Medline, The Cochrane Library, Embase, Scopus, CINAHL, or PsycINFO. Databases were searched in June 2022 and updated November 2023.

STUDY SELECTION

Inclusion criteria: age 18 years or older, traumatic SCI, and clinically significant depression (Population), mental health interventions including behavioral, pharmacologic, and complementary and alternative medicine (Intervention), inclusion of a control group (Comparator), with a primary outcome of depression symptom reduction (Outcome). Criteria were applied by multiple reviewers and disagreements were reconciled via unanimous decision among the entire research team. Eight articles of 2780 screened met the selection criteria.

DATA EXTRACTION

Data were extracted independently by multiple reviewers. Two reviewers independently assigned a quality score using the guidelines described by Hawker and associates and independently evaluated the risk of bias of each article using version 2 of the Cochrane risk-of-bias tool.

DATA SYNTHESIS

All studies assessed depressive symptoms during participant recruitment, screening, and/or at a baseline assessment stage. Pharmacotherapy with venlafaxine XR and several behavioral interventions appear promising, including an online mindfulness course and eye movement desensitization and reprocessing therapy. Remote interventions may be effective in reaching individuals who are unable to travel to in-person therapy sessions.

CONCLUSIONS

This systematic review provides valuable information for clinicians who treat individuals with SCI and comorbid major depressive disorder or significant depressive symptoms. It highlights the importance of considering a variety of interventions and individualizing treatment to meet individuals' needs and preferences. Future research should aim to identify effective interventions for treating depressive symptoms in individuals with SCI and optimal delivery methods for these interventions.

The efficacy of cognitive behavioral therapy for mental health and quality of life among individuals diagnosed with cancer: A systematic review and meta-analysis

OBJECTIVE

It has long been documented that cognitive behavioral therapy (CBT) has positive impacts on improving mental health (MH) and quality of life (QoL) in the general population, but investigations on its effect on cancer survivors remain limited, especially for QoL outcomes. The purpose of this meta-analysis is to investigate the effects of CBT as compared to control on cancer patients' MH and QoL outcomes. Control is defined in this study as standard therapy, waitlist control, and active/alternative therapy.

METHODS

In total, 154 clinical trials creating a sample size of 1627 individuals were collected. Analysis focusing on MH and QoL excluded 29 clinical trials resulting in a final analysis of 132 clinical trials (and 1030 effect sizes). R Statistical Software (version 4.2.2) and the robumeta package were utilized to complete analysis, which entailed robust variance estimation (RVE) in intercept-only meta-regression, and univariate meta-regression (for moderator analysis).

RESULTS

Across 132 clinical trials and 1030 effect size estimates, we identified that CBT moderately improves MH and QoL in cancer patients d = 0.388, 95% CI 0.294-0.483, p < 0.001. Additionally, age and delivery format can influence the efficacy of CBT in this patient population.

CONCLUSIONS

CBT statistically improves the MH and QoL psychosocial parameters in cancer patients with greater efficacy in younger patients. Important clinical and intervention-related factors, that is, age and delivery, should be considered when oncologists consider CBT as a psychotherapeutic intervention for individuals with cancer.

Predictors of engagement with between-session work in Cognitive Behavioural Therapy (CBT)-based interventions: a mixed-methods systematic review and "best fit" framework synthesis

Between-session work (BSW) acts as the vehicle to translate skills learnt in therapy sessions into adaptive changes in everyday life, a key goal in Cognitive Behavioural Therapies (CBT). Despite a well-established relationship between engagement with BSW and enhanced treatment outcomes, difficulties completing between-session tasks are common and factors affecting patient engagement with BSW are poorly understood. This mixed-methods systematic review and "best fit" framework synthesis explored predictors of engagement with BSW in CBT-based interventions. Comprehensive searches were conducted across five databases, identifying 59 eligible studies. This combined theory and empirical evidence approach depicted ten predictor themes related to between-session engagement, spanning individual, relational and contextual concepts. While ambiguous findings were generated by existing evidence, several factors emerged as relatively consistent predictors of engagement with BSW: positive patient beliefs regarding BSW and treatment such as perceived helpfulness, and practitioner competency in planning and reviewing BSW, including providing a rationale and addressing difficulties were associated with greater engagement. Conversely, patient in-session resistance, including counter change talk, was an indicator of disengagement between-sessions. The impact of patient symptomology, sociocultural environment, practitioner beliefs and the therapeutic relationship is unclear. The conceptual model presented offers a testable framework for researchers and a guideline for practitioners.

Enhancing quality of life in severe post-COVID-19 survivors through multidisciplinary care

Background

COVID-19 survivors who were hospitalised continue to experience long-term multisystemic sequelae and symptoms, impacting their health-related quality of life (HRQoL). The complexity of post-COVID-19 conditions underscores the importance of adopting a multidisciplinary, patient-centric approach to ensure ongoing care. This study aims to assess HRQoL and post-COVID symptoms in a cohort of severe COVID-19 survivors depending on their participation in a multidisciplinary programme.

Methods

This prospective study was conducted in a post-COVID clinic staffed by a multidisciplinary team (physical rehabilitator, nutritionist, psychologist, including experts in pulmonary rehabilitation, nutrition, psychology and others). Subjects over 18 years old who were hospitalised due to severe COVID-19 during the acute phase and had attended the post-COVID clinic within the first 3 months following discharge were included. Subjects who were unable or unwilling to provide informed consent to participate in the protocol were excluded. Linear mixed-effect models were employed to examine changes in 12-Item Short-Form Health Survey (SF-12) component scores. The resolution of post-COVID symptom clusters was compared using the Cox model.

Results

A total of 730 patients were included, with a mean±sd age of 55.78±15.43 years; 60.55% were male and 90.62% required mechanical ventilation during hospitalisation. Programme attendants demonstrated improved SF-12 physical and mental component scores at 3 and 12 months. A reduction in the prevalence of post-COVID symptoms was observed in both groups, with greater reductions in those attending the programme.

Conclusion

Our study showed that patients enrolled on the multidisciplinary programme experienced improvements in fatigue, musculoskeletal, gastrointestinal, neuropsychiatric and respiratory symptoms, along with enhanced SF-12 mental and physical component scores.

Psychological treatments for temporomandibular disorder pain-A systematic review

OBJECTIVE

Temporomandibular disorders (TMD) are common. They affect abilities for carrying out daily tasks and influence different psychological aspects. In addition to standard treatment, psychological treatments have been suggested. The aim was to investigate the effects of psychological treatments on patients with painful TMD in a short- and long-term perspective.

MATERIALS AND METHODS

An electronic search was conducted in the databases MEDLINE, CINAHL, EMBASE, the Cochrane Central Registry of Controlled Trials (CENTRAL), and Web of Science for randomized clinical trials (RCTs) reporting psychological interventions for TMD. Registered beforehand in PROSPERO (CRD42022320106). In total, 18 RCTs were included; six RCTs that could be used in the meta-analysis, and all 18 RCTs were used in the narrative synthesis. Risk of bias was assessed by the Cochrane's tool for assessing risk of bias and certainty of evidence by GRADE.

RESULTS

The narrative synthesis indicates that psychological treatment options seem equivalent to standard treatment for painful TMD. The meta-analysis showed that a combination of psychological treatment and standard treatment and manual treatment (very low-quality evidence) are significantly better in pain reduction than just counselling and standard treatments of TMD.

CONCLUSION

This study indicates that psychological treatments seem to reduce pain intensity in individuals with painful TMD, and that the effect seems to be equally good as standard treatment. However, a combination of psychological treatments and standard treatments seems to have an even better effect. This indicates that psychological treatments are promising as an additional treatment approach for painful TMDs.

Preliminary Impact of Group-Based Interventions on Stigma, Mental Health, and Treatment Adherence Among Adolescents Living with Human Immunodeficiency Virus in Uganda

OBJECTIVE

To examine the preliminary impact of group cognitive behavioral therapy and multiple family group-based family strengthening to address HIV stigma and improve the mental health functioning of adolescents living with HIV in Uganda.

STUDY DESIGN

We analyzed data from the Suubi4Stigma study, a 2-year pilot randomized clinical trial that recruited adolescents living with HIV (10-14 years) and their caregivers (n = 89 dyads), from 9 health clinics. We fitted separate three-level mixed-effects linear regression models to test the effect of the interventions on adolescent outcomes at 3 and 6 months post intervention initiation.

RESULTS

The average age was 12.2 years and 56% of participants were females. Participants in the multiple family group-based family strengthening intervention reported lower levels of internalized stigma (mean difference = -0.008, 95% CI = -0.015, -0.001, P = .025) and depressive symptoms at 3 months (mean difference = -0.34, 95% CI = -0.53, -0.14, P < .001), compared with usual care. On the other hand, participants in the group cognitive behavioral therapy intervention reported lower levels of anticipated stigma at 3 months (mean difference = -0.039, 95% CI = -0.072, -0.006), P = .013) and improved self-concept at 6 months follow-up (mean difference = 0.04, 95% CI = 0.01, 0.01, P = .025).

CONCLUSION

Outcome trends from this pilot study provide compelling evidence to support testing the efficacy of these group-based interventions on a larger scale.

TRIAL REGISTRATION

The study is registered in the Clinical trials.gov database (Identifier #: NCT04528732).

Predicting CBT modality, treatment participation, and reliable improvements for individuals with anxiety and depression in a specialized mental health centre: a retrospective population-based cohort study

BACKGROUND

Cognitive Behaviour Therapy (CBT) is one of the most successful therapeutic approaches for treating anxiety and depression. Clinical trials show that for some clients, internet-based CBT (eCBT) is as effective as other CBT delivery modes. However, the fidelity of these effects may be weakened in real-world settings where clients and providers have the freedom to choose a CBT delivery mode and switch treatments at any time. The purpose of this study is to measure the CBT attendance rate and identify client-level characteristics associated with delivery mode selection and having reliable and clinically significant improvement (RCSI) of treatment in each delivery mode in a real-world CBT outpatient program.

METHODS

This is a retrospective cohort analysis of electronic medical records collected between May 1, 2019, and March 31, 2022, at Ontario Shores Centre for Mental Health Sciences. Regression models were used to investigate the impact of individual client characteristics on participation and achieving RCSI of different CBT delivery modes.

RESULTS

Our data show a high attendance rate for two and more CBT sessions across all modalities (98% of electronic, 94% of group, 100% of individual, and 99% of mixed CBT). Individuals were more likely to enter mixed and group CBT modality if they were younger, reported being employed, and reported higher depression severity at the baseline. Among the four modalities of CBT delivery, group CBT clients were least likely to have RCSI. Of those who started sessions, clients were significantly more likely to experience RCSI on the Patient Health Questionnaire (PHQ)-9 and the Generalized Anxiety Disorder (GAD)-7 if they were employed, reported more severe symptoms at baseline, and were living in the most deprived neighborhoods.

CONCLUSIONS

This study will contribute to the body of knowledge about the implementation and treatment planning of different CBT delivery modes in real-world settings. With the changing clinical environment, it is possible to advocate for the adoption of the eCBT intervention to improve therapy practices and achieve better treatment success. The findings can help guide future CBT program planning based on client socio-demographic characteristics, allowing the optimal therapy type to be targeted to the right client at the right time.

Interventions to promote medical student well-being: an overview of systematic reviews

OBJECTIVE

To conduct an overview of systematic reviews that explore the effectiveness of interventions to enhance medical student well-being.

DESIGN

Overview of systematic reviews.

DATA SOURCES

The Cochrane Library of Systematic Reviews, MEDLINE, APA PsychInfo, CINAHL and Scopus were searched from database inception until 31 May 2023 to identify systematic reviews of interventions to enhance medical student well-being. Ancestry searching and citation chasing were also conducted.

DATA EXTRACTION AND SYNTHESIS

The Assessing the Methodological Quality of Systematic Reviews V.2 tool was used to appraise the quality of the included reviews. A narrative synthesis was conducted, and the evidence of effectiveness for each intervention was rated.

RESULTS

13 reviews (with 94 independent studies and 17 616 students) were included. The reviews covered individual-level and curriculum-level interventions. Individual interventions included mindfulness (n=12), hypnosis (n=6), mental health programmes (n=7), yoga (n=4), cognitive and behavioural interventions (n=1), mind-sound technology (n=1), music-based interventions (n=1), omega-3 supplementation (n=1), electroacupuncture (n=1) and osteopathic manipulative treatment (n=1). The curriculum-level interventions included pass/fail grading (n=4), problem-based curriculum (n=2) and multicomponent curriculum reform (n=2). Most interventions were not supported by sufficient evidence to establish effectiveness. Eleven reviews were rated as having 'critically low' quality, and two reviews were rated as having 'low' quality.

CONCLUSIONS

Individual-level interventions (mindfulness and mental health programmes) and curriculum-level interventions (pass/fail grading) can improve medical student well-being. These conclusions should be tempered by the low quality of the evidence. Further high-quality research is required to explore additional effective interventions to enhance medical student well-being and the most efficient ways to implement and combine these for maximum benefit.

Feasibility and Acceptability of Group-Based Stigma Reduction Interventions for Adolescents Living with HIV and Their Caregivers: The Suubi4Stigma Randomized Clinical Trial (2020-2022)

This study examined the feasibility and acceptability of two group-based interventions: group-cognitive behavioral therapy (G-CBT) and a family-strengthening intervention delivered via multiple family group (MFG-FS), to address HIV stigma among adolescents living with HIV (ALHIV) and their caregivers. A total of 147 adolescent -caregiver dyads from 9 health clinics situated within 7 political districts in Uganda were screened for eligibility. Of these, 89 dyads met the inclusion criteria and provided consent to participate in the study. Participants were randomized, at the clinic level, to one of three study conditions: Usual care, G-CBT or MFG-FS. The interventions were delivered over a 3-month period. While both adolescents and their caregivers attended the MFG-FS sessions, G-CBT sessions were only attended by adolescents. Data were collected at baseline, 3 and 6-months post intervention initiation. The retention rate was 94% over the study period. Across groups, intervention session attendance ranged between 85 and 92%, for all sessions. Fidelity of the intervention was between 85 and 100%, and both children and caregivers rated highly their satisfaction with the intervention sessions. ALHIV in Uganda, and most of sub-Saharan Africa, are still underrepresented in stigma reduction interventions. The Suubi4Stigma study was feasible and acceptable to adolescents and their caregivers -supporting testing the efficacy of the interventions in a larger trial.

Facilitators and barriers to "Positive Outcomes" from cognitive-behavioral therapy, according to young people: A thematic synthesis

OBJECTIVE

This qualitative review sought to explore how young people (YP) conceptualize positive outcomes from cognitive-behavioral therapy (CBT) and what YP perceive to be the facilitators and barriers to positive outcomes.

METHODS

A systematic literature search was conducted in June 2021 using six online databases. Studies were included if qualitative data were collected from participants who were aged up to 25, had internalizing mental health difficulties, and had received in-person CBT from trained practitioners.

RESULTS

Nineteen studies were included. The Gough Weight of Evidence framework was used to assess methodological and topical quality and relevance. A thematic synthesis identified 34 conceptualizations of positive outcomes, 57 facilitators, and 49 barriers. Descriptive and analytical themes were identified. In line with the review's pragmatic perspective, the latter were worded as practice recommendations: acknowledge YP's perspectives on outcomes, teach tangible CBT techniques, balance autonomy and support, frame CBT as "upskilling," explore nuanced barriers to engagement, and consider the power of group dynamics.

CONCLUSIONS

This review established the range of YP's views about positive outcomes from CBT, as well as facilitators and barriers to achieving these. Findings should prompt CBT practitioners to reflect and consider how their practice might be shaped through reports from YP as experts by experience.

Treatment of Depression in Huntington's Disease: A Systematic Review

Depression is a common psychiatric disorder among individuals with Huntington's disease (HD). Depression in HD and major depressive disorder appear to have different pathophysiological mechanisms. Despite the unique pathophysiology, the treatment of depression in HD is based on data from the treatment of major depressive disorder in the general population. The objective of this systematic review was to conduct a comprehensive evaluation of the available evidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies on the treatment of depression in HD were identified by searching MEDLINE, Embase, and PsycInfo. The initial search yielded 2,771 records, 41 of which were ultimately included. There were 19 case reports, seven case series, three cross-sectional studies, one qualitative study, nine nonrandomized studies, and two randomized trials among the included studies. The most common assessment tools were the Hospital Anxiety and Depression Scale (N=8), the Beck Depression Inventory (N=6), and the Hamilton Depression Rating Scale (N=6). Only 59% of the included studies assessed depressive symptoms with a scoring system. The pharmacological options for the treatment of depression included antidepressants and antipsychotics. Nonpharmacological approaches were multidisciplinary rehabilitation, psychotherapy, and neurostimulation. Limited evidence on the treatment of depression in HD was available, and this literature consisted mainly of case reports and case series. This systematic review highlights the knowledge gap and the pressing need for HD-specific research to determine the efficacy of treatment approaches for depression in HD.

The perceived helpfulness and acceptability of a bespoke psychological therapy service for registered nurses experiencing psychological distress: A qualitative study

AIM

To understand the perceived helpfulness and acceptability of a bespoke psychological therapy service for registered nurses. The service provided a free and confidential specialist mental health service to all healthcare professionals, including nurses and nursing students.

DESIGN

An exploratory study using a descriptive qualitative approach.

METHODS

A purposive sample of 20 registered nurses accessing a bespoke psychological therapy service in Wales participated in audio-recorded semi-structured interviews in January 2022. Transcribed data were analysed using reflexive thematic analysis.

RESULTS

Four interrelated themes were identified from the data analysis: COVID [SARS-CoV-2] changed things; You're a nurse, you're human; I've got 'me' back; and pretty close to miracle workers.

CONCLUSION

Participants attempted to live up to an idealized image of a nurse, generating self-stigmatizing beliefs that negatively affected their mental health. The psychological therapy service enabled participants to put their roles into perspective, that is, separate themselves from their role, be vulnerable, and develop confidence and adaptive coping strategies. Participants valued the minimal barriers and ease of access to support.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The complex relationship between nurse identity and the challenges of the workplace needs to be central to nurse education. Nurses can benefit from rapid access to a timely, confidential, and independent self-referring psychological therapy service.

IMPACT

This qualitative study explored the helpfulness and accessibility of psychological support for nurses. The main themes were that COVID changed things; You're a nurse, you're human; I've got 'me' back; and pretty close to miracle workers. The findings will impact how nurses are supported in the United Kingdom and worldwide.

REPORTING METHOD

This report adheres to the standards for reporting qualitative research (SRQR).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Improving movement behavior in office workers: effects of two multi-level cluster-RCT interventions on mental health

BACKGROUND

We have previously reported on the design and efficacy of two cluster-randomized multi-level workplace interventions, attempting to decrease sedentary behavior (SED) or increase moderate to vigorous physical activity (MVPA) among office workers to improve mental health outcomes. The aim of this study was to investigate intervention effects on mental health outcomes, i.e., mental wellbeing, depression or anxiety symptoms, and stress immediately after the 6-month intervention period.

METHODS

Teams of 263 office workers were cluster-randomized to one of two interventions or a waitlist control group. The PA intervention (iPA) focused on increasing MVPA and the SED intervention (iSED) on reducing SED. Both multi-level interventions targeted individual office workers and their social, physical, and organizational work environment, incorporating counseling based on cognitive behavioral therapy and motivational interviewing. Mental health outcomes were assessed using validated questionnaires before and immediately after the intervention. Intervention effects were analyzed using linear mixed effects models.

RESULTS

Participants were mostly female and highly educated, with a mean age of 42 years and had favorable levels of mental health at baseline. Mental wellbeing improved for the iSED group (β = 8, 95% CI 1 to 15, p = 0.030) but not for the iPA group (β = 6, 95% CI -1 to 12, p = 0.072) compared to the control group. No effects were found for depression or anxiety symptoms or stress.

CONCLUSIONS

The multi-level interventions improved mental wellbeing among this population of office workers, reaching statistical significance in the iSED group. The size of the effect can be regarded meaningful, considering favorable mental health and high PA level at baseline. Thus, workplace interventions that provide support on multiple levels appear to have potential for improving mental wellbeing, but not reducing ill-health variables, among healthy office workers. More research is needed to understand the mechanisms through which such improvements can be achieved and to identify the most effective intervention components.

TRIAL REGISTRATION

ISRCTN92968402 (27 February 2018).

Mind-body internet and mobile-based interventions for depression and anxiety in adults with chronic physical conditions: A systematic review of RCTs

This review summarizes the effectiveness of scalable mind-body internet and mobile-based interventions (IMIs) on depression and anxiety symptoms in adults living with chronic physical conditions. Six databases (MEDLINE, PsycINFO, SCOPUS, EMBASE, CINAHL, and CENTRAL) were searched for randomized controlled trials published from database inception to March 2023. Mind-body IMIs included cognitive behavioral therapy, breathwork, meditation, mindfulness, yoga or Tai-chi. To focus on interventions with a greater potential for scale, the intervention delivery needed to be online with no or limited facilitation by study personnel. The primary outcome was mean change scores for anxiety and depression (Hedges' g). In subgroup analyses, random-effects models were used to calculate pooled effect size estimates based on personnel support level, intervention techniques, chronic physical condition, and survey type. Meta-regression was conducted on age and intervention length. Fifty-six studies met inclusion criteria (sample size 7691, mean age of participants 43 years, 58% female): 30% (n = 17) neurological conditions, 12% (n = 7) cardiovascular conditions, 11% cancer (n = 6), 43% other chronic physical conditions (n = 24), and 4% (n = 2) multiple chronic conditions. Mind-body IMIs demonstrated statistically significant pooled reductions in depression (SMD = -0.33 [-0.40, -0.26], p<0.001) and anxiety (SMD = -0.26 [-0.36, -0.17], p<0.001). Heterogeneity was moderate. Scalable mind-body IMIs hold promise as interventions for managing anxiety and depression symptoms in adults with chronic physical conditions without differences seen with age or intervention length. While modest, the effect sizes are comparable to those seen with pharmacological therapy. The field would benefit from detailed reporting of participant demographics including those related to technological proficiency, as well as further evaluation of non-CBT interventions. Registration: The study is registered with PROSPERO ID #CRD42022375606.

A systematic review of cognitive behavioral therapy-based interventions for comorbid chronic pain and clinically relevant psychological distress

Objective

Chronic pain frequently co-occurs with clinically relevant psychological distress. A systematic review was conducted to identify the efficacy of cognitive behavioral therapy-based interventions for patients with these comorbid conditions.

Methods

The systematic search was carried out in Medline, PsycINFO, Web of Science, and Scopus up to March 18th, 2023. Four reviewers independently conducted screenings, extraction, and quality assessment.

Results

Twelve randomized controlled trials and one non-randomized controlled trial involving 1,661 participants that examined the efficacy of Cognitive Behavioral Therapy (nine studies), Mindfulness-based Interventions (three studies), Acceptance and Commitment Therapy (one study), and Behavioral Activation Therapy for Depression (one study) were included. Compared to treatment as usual, six out of eight studies of traditional Cognitive Behavioral Therapy reported significant differences in the reduction of depressive symptoms at post-treatment (d from 1.31 to 0.18) and four out of six at follow-up (d from 0.75 to 0.26); similarly, five out of six reported significant differences in the reduction of anxiety symptoms at post-treatment (d from 1.08 to 0.19) and three out of four at follow-up (d from 1.07 to 0.27). Overall, no significant differences between traditional Cognitive Behavioral Therapy and treatment as usual were reported at post-treatment and follow-up in the studies exploring pain intensity and pain catastrophizing.

Conclusion

The available evidence suggests that traditional Cognitive Behavioral Therapy may produce significant benefits for the improvement of depression, anxiety, and quality of life, but not for pain intensity and pain catastrophizing. More evidence is needed to determine the effects of MBI, ACT, and BATD.

Systematic review registration

PROSPERO, CRD42021219921.

Central neuropathic pain

Central neuropathic pain arises from a lesion or disease of the central somatosensory nervous system such as brain injury, spinal cord injury, stroke, multiple sclerosis or related neuroinflammatory conditions. The incidence of central neuropathic pain differs based on its underlying cause. Individuals with spinal cord injury are at the highest risk; however, central post-stroke pain is the most prevalent form of central neuropathic pain worldwide. The mechanisms that underlie central neuropathic pain are not fully understood, but the pathophysiology likely involves intricate interactions and maladaptive plasticity within spinal circuits and brain circuits associated with nociception and antinociception coupled with neuronal hyperexcitability. Modulation of neuronal activity, neuron-glia and neuro-immune interactions and targeting pain-related alterations in brain connectivity, represent potential therapeutic approaches. Current evidence-based pharmacological treatments include antidepressants and gabapentinoids as first-line options. Non-pharmacological pain management options include self-management strategies, exercise and neuromodulation. A comprehensive pain history and clinical examination form the foundation of central neuropathic pain classification, identification of potential risk factors and stratification of patients for clinical trials. Advanced neurophysiological and neuroimaging techniques hold promise to improve the understanding of mechanisms that underlie central neuropathic pain and as predictive biomarkers of treatment outcome.

Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition

Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond

BACKGROUND

Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.

AIMS

In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment.

METHOD

The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.

CONCLUSION

Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Body mapping for arts-based inquiry in mental health research: a scoping review

Traditional research methods have not yet yielded highly effective long-term mental health treatments and might not reflect diverse lived experiences. Body mapping, which is an arts-based research method, could complement the verbal data of existing approaches through its focus on visual and symbolic processes to understand subjective, embodied experiences related to mental health. We did a scoping review on the use of body mapping in research on mental health experiences and outcomes. We searched Web of Science, PubMed, Scopus, PsycINFO, Embase, Ovid Medline, and Google Scholar to retrieve peer-reviewed articles in English. In 19 articles representing 17 studies, participant numbers for body mapping ranged from three to 48, and some studies exclusively recruited women or children and young people. Study domains included primary mental health experiences and mental health in relation to physical health or social experiences. The benefits of body mapping included its exploration of difficult-to-access emotions and experiences, its focus on strength and resilience, the therapeutic effect, its participatory and collaborative nature, its empowerment and dissemination of participants' voices, and the engagement of children and young people. Body mapping holds promise for research with marginalised groups typically excluded from mental health research.

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

BACKGROUND AND OBJECTIVE

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

METHODS

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

RESULTS AND CONCLUSION

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

SIGNIFICANCE

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.

An empirical investigation of the associations between metacognition, mindfulness experiential avoidance, depression, and anxiety

BACKGROUND

The aims of this study were to explore the possible relation between metacognition, mindfulness, and experiential avoidance, as well as their association with symptoms of anxiety and depression.

METHODS

Cross-sectional data was collected from a community sample (N = 364) who completed the Metacognitions Questionnaire-30 (MCQ-30), the Five Facet Mindfulness Questionnaire-24 (FFMQ-24), the Acceptance and Action Questionnaire-II (AAQ-II), the Generalized Anxiety Disorder 7-item (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

There were moderate-strong associations between mindfulness (FFMQ-24), metacognition (MCQ-30), and experiential avoidance (AAQ-II) (0.62 - 0.67), and they showed similar relations with symptoms of depression (PHQ-9) and anxiety (GAD-7) (0.57 - 0.71). Mindfulness, experiential avoidance, and the non-judging subscale of FFMQ-24 constituted a latent factor of flexibility in cognition and emotional experience, while three FFMQ-24 subscales (describing, acting with awareness, and observing) constituted a present-centered attention and awareness factor. Regression analyses indicated that flexibility explained more of the variance in symptoms of anxiety and depression than present-centered attention and awareness.

CONCLUSIONS

The results suggest that flexibility in cognitive and emotional regulation skills could be important in explaining symptoms of anxiety and depression.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base

OBJECTIVE

To map and examine the systematic review evidence base regarding the effects of cognitive-behavioral therapy (CBT) for eating disorders (EDs), especially against active interventions.

METHOD

This systematic review is an extension of an overview of CBT for all health conditions (CBT-O). We identified ED-related systematic reviews from the CBT-O database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in April 2021 and September 2022.

RESULTS

The 44 systematic reviews included (21 meta-analyses) were of varying quality. They focused on "high intensity" CBT, delivered face-to-face by qualified clinicians, in BN, BED and mixed, not specifically low-weight samples. ED-specific outcomes were studied most, with little consensus on their operationalization. The, often insufficient, reporting of sample characteristics did not allow assessment of the generalizability of findings. The meta-analytic syntheses show that high intensity one-to-one CBT produces better short-term effects than a mix of active controls especially on ED-specific measures for BED, BN, and transdiagnostic samples. There is little evidence favoring group CBT or low intensity CBT against other active interventions.

DISCUSSION

While this study found evidence consistent with current ED treatment recommendations, it highlighted notable gaps that need to be addressed. There were insufficient data to allow generalizations regarding sex and gender, age, culture and comorbidity and to support CBT in AN samples. The evidence for group CBT and low intensity CBT against active controls is limited, as it is for the longer-term effects of CBT. Our findings identify areas for future innovation and research within CBT.

PUBLIC SIGNIFICANCE

This study provides a comprehensive mapping and quality assessment of the current large systematic review research base regarding the effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus on comparisons to other active interventions. By transcending the more limited scope of individual systematic reviews, this overview highlights the gaps in the current evidence base, and thus provides guidance for future research and clinical innovation.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis

BACKGROUND

Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables.

METHODS

We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed.

RESULTS

We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome.

CONCLUSIONS

People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

Explore your brain: A randomized controlled trial into the effectiveness of a growth mindset intervention with psychosocial and psychophysiological components

BACKGROUND

Although past research demonstrated growth mindset interventions to improve school outcomes, effects were small. This may be due to the theoretical nature of psychosocial techniques (e.g., reading about brain plasticity), which may not be optimally convincing for students.

AIMS

To address this issue and improve effectiveness, we developed a growth mindset intervention, which combined psychosocial and psychophysiological components. The latter adds a convincing experience of influencing one's own brain activity, using mobile electroencephalography (EEG) neurofeedback, emphasizing the controllable and malleable nature of one's brain.

SAMPLE

In this randomized controlled trial (RCT), twenty high-school classes (N = 439) were randomized to either the active control condition (no mindset messaging) or our newly developed growth mindset intervention condition (4 × 50 min).

METHODS

School outcomes (pre, post, 1-year follow-up) were analysed with Linear Mixed Models (LMM: variable-oriented) and Latent Transition Analysis (LTA: person-oriented).

RESULTS

LMM: students in the growth mindset intervention reported increased growth mindset directly after the intervention (post, d = .38) and at 1-year follow-up (d = .25) and demonstrated a protective effect against deterioration of math grades at 1-year follow-up (d = .36), compared to controls. LTA: we identified three mindset profiles (Fixed, Growth competitive, Growth non-competitive), with more frequent transitions from fixed to one of the growth mindset profiles at 1-year follow-up for students in the growth mindset intervention compared to controls (OR 2.58-2.68).

CONCLUSIONS

Compared to previous studies, we found relatively large effects of our intervention on growth mindset and math grades, which may be attributable to synergetic effects of psychosocial and psychophysiological (neurofeedback) components. The person-oriented approach demonstrated more holistic effects, involving multiple motivational constructs.

Patient engagement in the development of CF-CBT: A cystic fibrosis-specific cognitive-behavioral intervention for adults

Individuals with cystic fibrosis (CF) are at high risk for depression and anxiety, with negative consequences for health and quality of life. Cystic Fibrosis Foundation/European Cystic Fibrosis Society guidelines recommend routine screening, treatment, and preventative efforts. Cognitive-behavioral therapy (CBT) has a large evidence-base for depression/anxiety prevention and treatment. However, traditional CBT protocols require adaptation to address the emotional challenges of coping with CF, stressors related to disease management, and barriers to access to care. The goal of this study was to partner with the CF community to develop an innovative CBT-based intervention for the prevention and treatment of depression and anxiety tailored to CF-specific needs. In-depth feedback was collected via audio-recorded telephone interviews with 16 adults with CF from 3 U.S. CF centers, with purposive sampling across gender, age, ethnicity, and disease severity. A semi-structured interview guide elicited discussion of patient experiences of coping with CF, and perspectives on the acceptability of the content, structure, and delivery model of the proposed intervention. Qualitative analysis utilized a content analytic approach. Participants ranged from 21 to 53 years (M = 35); eight were female; three were Hispanic. Patient-reported most recent FEV1, a measure of lung function based on forced expiratory volume in in one second, ranged from 25 to 113% predicted (M = 72). One participant was post-double lung transplant. Qualitative interviews were analyzed thematically revealing core themes related to the experience of coping with CF. The most frequently cited CF-related stressors were Treatment Burden, Illness Uncertainty, and Financial/Insurance Stress. Participants talked about the interaction of physical symptoms and emotional distress in their daily lives, a topic not typically discussed in routine CF care. Resilience was also a major theme with participants describing strategies they use to cope with CF and hospitalizations. Description of patients' experiences was incorporated into the program's intervention manual and patient workbook. Participants also provided direct feedback on the proposed program. Feedback was largely positive regarding program content and structure, suggesting the acceptability of a CF-specific CBT-based intervention for adults with CF. Features to increase accessibility of care including telehealth, inpatient delivery, and team-based care were perceived as advantageous, and participants emphasized the value of a CF-specific mental health intervention. Qualitative findings directly informed the development of CF-CBT, a cognitive-behavioral skills-based program to promote emotional well-being for adults with CF.

For whom and what outcomes does cognitive-behavioral-therapy work among cancer survivors: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of CBT for individuals diagnosed with cancer across a broad range of outcome domains, i.e., functional health, psychological health, health behaviors, social relational, and general wellness.

METHODS

A comprehensive search of 7 databases, 91 published reviews, and 4 professional websites was performed on August 30th, 2021. English-language clinical trials of CBT for cancer patients/survivors were included. Studies were independently screened, and data were extracted by 2 reviewers, and discrepancies were resolved by consensus among the investigative team. A total of 151 clinical trials (154 articles) published between 1986 and 2021 were included in the analysis.

RESULTS

CBT was overall effective for cancer patients/survivors in the domains of functional health, g = 0.931, p < 0.001, psychological health, g = 0.379, p < 0.001, and general wellness, g = 0.257, p < 0.001, but ineffective in domains of health behaviors, g = 0.792, p > 0.05, and social relational outcomes, g = 0.319, p > 0.05. Additional subgroup and moderator analyses further revealed CBT's differential treatment effect for different within domain outcomes, across different cancer disease stages, and CBT delivery format.

CONCLUSIONS

Findings of the study showed that CBT is an effective treatment for individuals diagnosed with cancer. However, treatment effects differ by important disease- and intervention-related factors, which should be considered when recommending CBT for cancer patients/survivors.

Further validation of the Cognitive Biases Questionnaire for psychosis

BACKGROUND

Cognitive biases are recognized as important treatment targets for reducing symptoms associated with severe mental disorders. Although cognitive biases have been linked to symptoms in most studies, few studies have looked at such biases transdiagnostically. The Cognitive Bias Questionnaire for psychosis (CBQp) is a self-reported questionnaire that assesses cognitive biases amongst individuals with a psychotic disorder, as well as individuals with other severe mental disorders. The current study aims to validate a French version of the CBQp and to explore transdiagnostic cognitive biases in individuals with psychotic disorders, individuals with depression, and in healthy controls.

METHODS

The CBQp was translated into French following a protocol based on international standards. Discriminant validity and internal consistency were determined for total score and each subscale score. Confirmatory factor analyses were performed to test construct validity. Finally, cluster analyses were conducted to investigate cognitive biases across diagnostic groups.

RESULTS

Our results were similar to those of the original authors, with the one-factor solution (assessment of a general thinking bias) being the strongest, but the two-factor solution (assessing biases within two themes relating to psychosis) and the five-factor solution (assessment of multiple distinct biases) being clinically more interesting. A six-cluster solution emerged, suggesting that individuals with similar diagnoses score differently on all cognitive biases, and that individuals with different diagnoses might have similar cognitive biases.

CONCLUSIONS

The current findings support the validity of the French translation of the CBQp. Our cluster analyses overall support the transdiagnostic presence of cognitive biases.

The Effects of Psychological Interventions on Symptoms and Psychology of Functional Dyspepsia: A Systematic Review and Meta-Analysis

Background

The effects of psychological interventions on symptoms and psychology of functional dyspepsia (FD) remain unclear. We aimed to comprehensively evaluate the effects of psychological interventions on symptoms and psychology of FD.

Methods

We searched the PubMed, Cochrane Library, and Embase electronic databases for randomized controlled trials (RCTs) evaluating the role of psychological interventions in FD patients published before July 2021. Standardized mean differences (SMDs), risk ratios (RRs) and 95% confidence intervals (CIs) were calculated by a random effects model. Subgroup analyses and sensitivity analyses were also performed.

Results

Fourteen RCTs with a total of 1,434 FD patients were included. Compared with the control group, psychological interventions were significantly more likely to symptom improvement [RR = 1.74, 95% CI (1.12, 2.72), p = 0.01], relieve gastrointestinal symptoms scores at follow up [SMD = −1.06, 95% CI (−1.55, −0.57), p < 0.0001], relieve gastrointestinal symptoms scores at end of treatment [SMD = −0.98, 95% CI (−1.29, −0.67), p < 0.001], decrease anxiety [SMD = −0.8, 95% CI (−1.38, −0.22), p = 0.006] and depression levels [SMD = −1.11, 95% CI (−1.62, −0.61), p < 0.001]. The results of the subgroup analysis showed that psychotherapy was more likely to symptom improvement, relieve gastrointestinal symptoms scores and decreased depression levels compared to the control.

Conclusions

Psychological interventions may be effective in alleviating the symptoms and psychology of FD, but the effect appears to be limited to psychotherapy with fewer trials for other psychological interventions. More data from high-quality RCTs are needed to confirm their use in the treatment of FD.

A trans-diagnostic cognitive behavioural conceptualisation of the positive and negative roles of social media use in adolescents’ mental health and wellbeing

Whilst research into the association between social media and mental health is growing, clinical interest in the field has been dominated by a lack of theoretical integration and a focus on pathological patterns of use. Here we present a trans-diagnostic cognitive behavioural conceptualisation of the positive and negative roles of social media use in adolescence, with a focus on how it interacts with common mental health difficulties. Drawing on clinical experience and an integration of relevant theory/literature, the model proposes that particular patterns of social media use be judged as helpful/unhelpful to the extent that they help/hinder the adolescent from satisfying core needs, particularly those relating to acceptance and belonging. Furthermore, it introduces several key interacting processes, including purposeful/habitual modes of engagement, approach/avoidance behaviours, as well as the potential for social media to exacerbate/ameliorate cognitive biases. The purpose of the model is to act as an aide for therapists to collaboratively formulate the role of social media in young people’s lives, with a view to informing treatment, and ultimately, supporting the development of interventions to help young people use social media in the service of their needs and values.

Key learning aims

(1)

Evidence-based practice in cognitive-behavioural therapy

Cognitive-behavioural therapy (CBT) is a practical, goal-focused approach that helps children understand the relationship between their thoughts, feelings and behaviours. The aim is to identify the dysfunctional and distorted cognitions associated with their psychological problems and to create more functional and balanced cognitive patterns that create less emotional distress and more helpful behaviours. CBT has strong evidence as an effective intervention for children and adolescents with emotional problems. The benefits for children with physical health and chronic conditions appear promising, although further research is required to substantiate these gains.

Acceptability and effectiveness of CBT and psychologically based interventions for emergency department attenders with medical complaints: a systematic literature review

This systematic literature review surveyed the evidence for the acceptability and effectiveness of CBT and psychologically based interventions for emergency department (ED) attenders with physical health complaints as their primary concern, in light of over-burdened EDs and the existing evidence base for psychological interventions in other medical settings. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018087860). A systematic search of three databases (APAPsychNet, Cochrane and PubMed) was performed to identify psychological treatment studies targeting physical health problems presenting in the ED, with broad inclusion criteria to capture a coherent understanding of the current knowledge base. A total of 2606 potential studies for inclusion were identified; 45 proceeded to full review. Twenty papers met the full inclusion. Included studies covered four clinical areas: trauma/PTSD-prevention, panic attacks, non-cardiac chest-pain and miscellaneous. A narrative description of findings reflected positive outcomes across all groups, but this was not consistent across any group. Few studies measured ED attendance (20%) or satisfaction/acceptability (10%). The majority of studies (90%) were underpinned by a cognitive behavioural framework, consistent with the current evidence base as applied to the management of medical conditions. Findings suggest there is some evidence that interventions in the ED are effective and acceptable to patients, but interpretation of findings is limited by the mixed quality of designs and risk of bias.

Key learning aims

(1)

Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol

Background

Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation.

Methods

We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use.

Discussion

Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Changes in Community Clinicians' Attitudes and Competence following a Transdiagnostic Cognitive Behavioral Therapy Training

Background

Although the literature suggest that attitudes toward evidence-based practices (EBPs) are associated with provider use of EBPs, less is known about the association between attitudes and how competently EBPs are delivered. This study examined how initial attitudes and competence relate to improvements in attitudes and competence following EBP training.

Methods

Program evaluation data was collected during implementation of an EBP in a large community mental health network. Clinicians (N=891) received intensive training in cognitive behavioral therapy followed by six months of consultation. Attitudes were assessed using the Evidence-Based Practice Attitude Scale, and competence was assessed using the Cognitive Therapy Rating Scale. Data were analyzed by fitting three latent change score models to examine the relationship between changes in attitudes and competence across the training and within its two phases (workshop phase, consultation phase).

Results

Latent change models identified significant improvement in attitudes (Ms _latent change≥1.03, SEs≤ 0.18, zs≥6.55, ps< .001) and competence (Ms _{latent change} ≥14.16, SEs≤3.10, zs≥2.82, ps<.001) across the full training and in each phase. Higher pre-workshop attitudes predicted significantly greater change in competence in the workshop and across training (bs≥1.62, SEs≤0.90, z≥1.09, p<.04, β≥0.10); however, contrary to our hypothesis, post-workshop attitudes did not significantly predict change in competence in consultation (b=1.62, SE=0.86, z=1.87, p=.06, β=0.09). Change in attitudes and change in competence in the training period and within the two phases were not significantly correlated.

Conclusions

Results indicate that pre-training attitudes about EBPs present a target for implementation interventions, given their relation to changes in both attitudes and competence throughout training. Following participation in in itial training workshops, other factors such as subjective norms, implementation culture, or system-level policy shifts may be more predictive of change in competence through consultation.