Effectiveness of a culturally adapted cognitive behavioural therapy-based guided self-help (CACBT-GSH) intervention to reduce social anxiety and enhance self-esteem in adolescents: a randomized controlled trial from Pakistan

Cognitive behavioral group therapy for social anxiety disorder - A critical review of methodological designs

Social anxiety disorder (SAD) is highly prevalent with significant lifetime impacts, especially when left untreated. Cognitive behavioral therapy is the current gold standard treatment with successful patient outcomes. Cognitive behavioral group therapy (CBGT) is one form that provides unique benefits to participants including normalization of symptoms and social support, as well as providing increased access to treatment at a lower per-session cost. Research on this mode of treatment has been ongoing for over 20 years, but we still have much to learn about its overall efficacy. The goals of this critical review were to summarize and evaluate the most current research, including an analysis of the overall methodological design quality, and provide recommendations for the enhancement of future studies based on best practices. Recent studies included some best practice design elements used in measuring efficacy such as the use of comparison groups, masking procedures, fidelity assessments, and consideration of clinical significance in outcomes. However, many gaps exist such as a lack of consensus around measures and therapy manuals, as well as baseline competencies of facilitators. Future studies should consider incorporating additional best practice elements aligning with study goals to strengthen designs and provide the field with even more confidence in this mode of treatment.

Supervisor's neuroticism and problematic Internet use among graduate students: the mediating role of supervisor-student relationship quality and the moderating role of fear of the supervisor's negative evaluation

BACKGROUND

Graduate students exhibit vulnerability to problematic Internet use, which can result in adverse physical, psychological, and social consequences. However, limited studies have addressed this issue among graduate students, and even fewer have explored the unique factors contributing to their problematic Internet use. Therefore, to address this gap, the current study aims to probe the relationship between supervisor's neuroticism and problematic Internet use among graduate students, the mediating effect of the supervisor-student relationship quality, as well as the moderating effect of fear of the supervisor's negative evaluation.

METHODS

A cross-sectional study was conducted in 2018 at three universities in Beijing, China. Anonymous data from 448 graduate students were collected regarding problematic Internet use, supervisor's neuroticism, supervisor-student relationship quality, and the fear of the supervisor's negative evaluation. A moderated mediation analysis was performed using Hayes' PROCESS macro (Model 14).

RESULTS

Supervisor's neuroticism was positively linked to graduate students' problematic Internet use, supervisor-student relationship quality mediated the linkage, and fear of the supervisor's negative evaluation played a moderating role in the second stage. Specifically, for students lower in fear of the supervisor's negative evaluation, supervisor-student relationship quality negatively predicted students' problematic Internet use. While for the graduate students higher in fear of the supervisor's negative evaluation, supervisor-student relationship quality could not significantly predict students' problematic Internet use. The mediating effect was only significant for graduate students lower in fear of the supervisor's negative evaluation.

CONCLUSIONS

This study established a theoretical model linking supervisor's neuroticism to graduate students' problematic Internet use, highlighting the potential roles of supervisor-student relationship quality and fear of the supervisor's negative evaluation. Reducing the neuroticism level of the supervisor, enhancing the quality of the supervisor-student relationship, and mitigating students' fear of the supervisor's negative evaluation will contribute to the reduction of problematic Internet use among graduate students.

Effectiveness of a spiritual adaptation of cognitive behavioural therapy in improving resilience, self-esteem and spirituality among clients with opioid use disorder: A quasi-experimental study

WHAT IS KNOWN ON THE SUBJECT?: Opioid use disorder (OUD) is a prevalent problem among Egyptian youth, and achieving recovery and abstinence is challenging. Cognitive behavioural therapy (CBT), a well-known approach, can be particularly beneficial when it addresses psychological aspects such as resilience and self-esteem. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Our research is recognized as a trailblazer in integrating a spiritual adaptation of CBT with spiritual elements for treating patients with OUD in the Egyptian context. This innovative approach marks a significant advancement in the field. The study found a statistically significant increase in the mean scores of resilience, self-esteem, and spirituality (p < .001 each) following the spiritual adaptation of CBT sessions compared to the control group. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings can guide psychiatrists and nurses in providing more comprehensive and effective care to patients with OUD by incorporating a spiritual adaptation of CBT with spiritual components into treatment plans.

ABSTRACT

INTRODUCTION: Opioid use disorder (OUD) is a prevalent problem among Egyptian youth, and achieving recovery and abstinence is challenging. Cognitive behavioural therapy (CBT), a well-known approach, can be particularly beneficial when it addresses psychological aspects such as resilience, self-esteem and spirituality.

AIM

This study aimed to evaluate the effectiveness of a spiritual adaptation of CBT in enhancing these factors among clients with OUD.

METHODS

A quasi-experimental study with a control group was conducted using a pretest-posttest design. The study included 49 clients with OUD and 46 clients in the control group. The Rosenberg Self-Esteem Scale-Modified Arabic Version, Daily Spiritual Experience Scale, and the Connor-Davidson Resilience Scale were used as measurement tools. CBT was delivered in 60-min group sessions. After 3 months, the questionnaires were re-administered to evaluate the effectiveness of a spiritual adaptation of CBT sessions.

RESULTS

The study found a statistically significant increase in the mean scores of resilience, self-esteem and spirituality (p < .001 each) following a spiritual adaptation of CBT sessions compared to the control group.

DISCUSSION

A spiritual adaptation of CBT effectively enhanced resilience, self-esteem and spirituality in clients with OUD.

IMPLICATIONS FOR PRACTICE

Understanding the effectiveness of a spiritual adaptation of CBT in enhancing resilience, self-esteem and spirituality can enable psychiatrists and nurses to provide more comprehensive and effective care to patients with OUD.

The Association Between Proneness to Smartphone Addiction and Social Anxiety Among School Students and the Mediating Role of Social Support: A Call to Advance Jordanian Adolescents' Mental Health

BACKGROUND

Social anxiety is an emerging public health issue associated with significant impairment of social functioning during adolescence. Among many determinants of social anxiety, proneness to smartphone addiction may significantly contribute to the development of social anxiety. To cope with the consequential development of social anxiety, adolescent school students may rely on various forms of social support. Particularly in the Middle East, including Jordan, the relationship between proneness to smartphone addiction and adolescent social anxiety is understudied.

AIM

To examine the mediating role of social support in the relationship between proneness to smartphone addiction and social anxiety in a sample of adolescent school students.

METHODS

In this cross-sectional study, 432 adolescents were recruited via a random cluster sample from public schools across three provinces in Jordan. The data were collected face-to-face using the Social Anxiety Scale for Adolescents, the Smartphone Addiction Proneness Scale, and the Multidimensional Scale of Perceived Social Support.

RESULTS

Significantly higher levels of social anxiety were associated with females of lower economic status who reported more gaming hours and higher levels of proneness to smartphone addiction. Familial social support significantly mediated the relationship between proneness to smartphone addiction and social anxiety, controlling for the other covariates in the social anxiety model.

CONCLUSIONS

Familial social support reduced the impact of proneness to smartphone addiction on social anxiety. Nurses may supplement treatment for reducing social anxiety in adolescents suffering from proneness to smartphone addiction by fostering sources of familial social support.

Feasibility of Guided Internet-Based Cognitive Behavioral Therapy for Panic Disorder and Social Anxiety Disorder in Japan: Pilot Single-Arm Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is effective in treating anxiety disorders. Accessibility to CBT has been limited in Japan due to the shortage of therapists. While an open-source e-learning system can be used to create a simple internet-based cognitive behavioral therapy (ICBT) program, the safety and outpatient acceptance of this treatment approach have not been explored in Japan.

OBJECTIVE

The aim of this study was to investigate whether outpatients with anxiety disorders could accept and successfully complete the ICBT program with guidance by CBT therapists when implementing therapeutic modules and CBT tasks. Due to being in the initial phase of a novel treatment in Japan, this study was intended for verification with a small sample size.

METHODS

In total, 6 adults, including 4 male participants and 2 female participants, were enrolled in a single-arm trial. The intervention involved guided ICBT comprising 12 sessions, including CBT text, comprehension confirmation tests, and explanatory videos about cognitive behavioral models, accessible through a website. The therapist guided the participants in accessing the ICBT program and answering their questions using a chat tool. The primary outcome was anxiety severity assessed using the State-Trait Anxiety Inventory-Trait. Secondary outcomes included the Panic Disorder Severity Scale, Liebowitz Social Anxiety Scale (LSAS), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Working Alliance Inventory-Short Form (WAI-SF). Statistical analyses were performed using paired 2-tailed t tests to assess the changes in clinical symptoms. The total WAI-SF score at the final session was used to evaluate the therapeutic alliance. For statistical analyses, mean changes for total State-Trait Anxiety Inventory-Trait, BAI, Panic Disorder Severity Scale, LSAS, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scores were analyzed using the paired 2-tailed t test. The 2-sided significance level for hypothesis testing was set at 5%, and 2-sided 95% CIs were calculated.

RESULTS

Most participants diligently engaged with the ICBT program. No adverse events were reported. The mean total scores for the primary outcome decreased by 11.0 (SD 9.6) points (95% CI -22.2 to 0.20; Hedges g=0.95), but it was not statistically significant. The mean total scores for the secondary outcomes that assess clinical symptoms decreased, with a significant reduction observed in the BAI of 15.7 (SD 12.1) points (95% CI -28.4 to -3.0; P=.03; Hedges g=1.24). The mean total scores for PDSS and LSAS decreased significantly, by 12.0 (SD 4.24) points (95% CI -50.1 to 26.1; P=.16; Hedges g=1.79) and 32.4 (SD 11.1) points (95% CI -59.7 to -4.3; P=.04; Hedges g=1.38), respectively. Of the participants, 67% (n=4) showed treatment response, and 50% (n=3) achieved remission after the intervention. The therapeutic alliance, measured using the WAI-SF, was moderate.

CONCLUSIONS

Guided ICBT may be feasible for the treatment of outpatients with panic disorder and social anxiety disorder in Japan.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry UMIN0000038118; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043439.

Social anxiety, self-esteem and quality of life among hypertensive patients during COVID-19 local epidemic in China: A mediation analysis

OBJECTIVES

To explore the mediating role of self-esteem in social anxiety and QoL during the COVID-19 local epidemic in China.

DESIGN

A cross-sectional survey.

METHODS

This study conveniently selected 344 hypertensive patients from a Grade-A tertiary hospital in Wuhu, Anhui Province, as the study population. Participants completed the demographic questionnaire, the social phobia inventory, the self-esteem scale and the 36-item short-form health survey.

RESULTS

Social anxiety, self-esteem and QoL were significantly correlated with each other. Social anxiety showed no direct effect on QoL (β = 0.011, p > 0.05). Social anxiety showed an indirect effect on QoL (β = -0.248, p < 0.001). Self-esteem fully mediated the association between social anxiety and QoL in hypertensive patients.

PATIENT OR PUBLIC CONTRIBUTION

Hypertensive patients in this study were participants during the data collection process. Nursing staff from the cardiology department at the hospital of a hospital in Wuhu City, Anhui Province assisted in the recruitment phase of the data collection process.

Research Review: Psychological and psychosocial interventions for children and adolescents with depression, anxiety, and post-traumatic stress disorder in low- and middle-income countries - a systematic review and meta-analysis

BACKGROUND

The incidence of depression, anxiety, and post-traumatic stress disorder (PTSD) among children and adolescents residing in low- and middle-income countries (LMICs) poses a significant public health concern. However, there is variation in the evidence of effective psychological interventions. This meta-analysis aims to provide a complete overview of the current body of evidence in this rapidly evolving field.

METHODS

We conducted searches on PubMed, Embase.com, and EBSCO/APA PsycInfo databases up to June 23, 2022, identify randomized controlled trials (RCTs) investigating the effectiveness of psychological interventions in LMICs that targeted children and adolescents with elevated symptoms above a cut-off score for depression, anxiety, and PTSD, comparing a psychological or psychosocial intervention with other control conditions. We conducted random effects meta-analyses for depression, anxiety, and PTSD symptoms. Sensitivity analysis for outliers and high-risk studies, and analyses for the publication bias were carried out. Subgroup analyses investigated how the intervention type, intervention format, the facilitator, study design, and age group of the participant predicted effect sizes.

RESULTS

Thirty-one RCTs (6,123 participants) were included. We found a moderate effect of interventions on depression outcomes compared to the control conditions (g = 0.53; 95% CI: 0.06-0.99; NNT = 6.09) with a broad prediction interval (PI) (-1.8 to 2.86). We found a moderate to large effect for interventions on anxiety outcomes (g = 0.88; 95% CI: -0.03 to 1.79; NNT = 3.32) with a broad PI (-3.14 to 4.9). Additionally, a moderate effect was observed on PTSD outcomes (g = 0.54; 95% CI: 0.19-0.9; NNT = 5.86) with a broad PI (-0.64 to 1.72).

CONCLUSIONS

Psychological and psychosocial interventions aimed at addressing depression, anxiety, and PTSD among children and adolescents in LMICs have demonstrated promising results. However, future studies should consider the variation in evidence and incorporate long-term outcomes to better understand the effectiveness of these interventions.

Effects of a culturally adapted counselling service for low-income ethnic minorities experiencing mental distress: a pragmatic randomised clinical trial

BACKGROUND

Culturally competent early mental health interventions for ethnic minorities (EMs) with no formal diagnoses are needed.

OBJECTIVES

To determine whether 8-12 weeks culturally adapted counselling (CAC) is better than waiting (waitlist (WL) group) to reduce depressive and anxiety symptoms and stress levels among EMs with elevated mental distress.

METHODS

Hong Kong EMs with mild and above-mild mental distress were randomly assigned to CAC or WL in this pragmatic, randomised, WL-controlled trial. The CAC group received the intervention after randomisation and the WL group received the intervention after 8-12 weeks (T1). The prespecified primary outcomes were depressive and anxiety symptoms and stress levels measured by the Depression, Anxiety and Stress subscales of the Depression, Anxiety and Stress Scale (DASS-D, DASS-A and DASS-S, respectively) at postintervention (T1, 8-12 weeks).

FINDINGS

A total of 120 participants were randomly assigned to either CAC (n=60) or WL (n=60), of whom 110 provided primary outcome data. At T1, CAC led to significantly lower depressive and anxiety symptom severity and stress levels compared with waiting, with unstandardised regression coefficients of -8.91 DASS-D points (95% CI -12.57 to -5.25; d=-0.90),-6.33 DASS-A points (95% CI -9.81 to -2.86; d=-0.68) and -8.60 DASS-S points (95% CI -12.14 to -5.06; d=-0.90).

CONCLUSIONS

CAC clinically outperformed WL for mild and above-mild levels of mental distress in EMs.

CLINICAL IMPLICATIONS

Making CAC routinely available for EMs in community settings can reduce healthcare burden.

TRIAL REGISTRATION NUMBER

NCT04811170.

Relationships among inferiority feelings, fear of negative evaluation, and social anxiety in Chinese junior high school students

Introduction

This study aimed to explore the relationship between feelings of inferiority and social anxiety in Chinese junior high school students. In addition, it examined the potential mediating effect of fear of negative evaluation in this relationship.

Methods

A survey was administered to a sample of 734 Chinese junior high school students. The Feelings of Inadequacy Scale, Brief Fear of Negative Evaluation Scale, and Social Avoidance Distress Scale were used.

Results

First, there were significant positive correlations between all subscales for the inferiority feelings, social anxiety, and fear of negative evaluation. Furthermore, fear of negative evaluation mediated the predictive effects of four inferiority subscales (i.e., self-esteem, academic ability, appearance, and physical ability) for social anxiety. However, the total score for the sense of inferiority and social confidence subscale lacked this mediating effect.

Conclusion

The inferiority feelings of self-esteem, academic ability, appearance, and physical ability may directly and indirectly predict social anxiety through fear of negative evaluation.

Meta-analysis: The Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries

OBJECTIVE

Because most youth psychotherapies are developed and tested in high-income countries, relatively little is known about their effectiveness or moderators in low- and middle-income countries (LMICs). To address this gap, we conducted a meta-analysis of randomized controlled trials (RCTs) testing psychotherapies for youth with multiple psychiatric conditions in LMICs, and we tested candidate moderators.

METHOD

We searched 9 international databases for RCTs of youth psychotherapies in LMICs published through January 2021. The RCTs targeted elevated symptoms of youth anxiety (including post-traumatic stress disorder [PTSD] and obsessive-compulsive disorder), depression, conduct problems, and attention problems. Using robust variance estimation, we estimated the pooled effect sizes (Hedges g) at post treatment and follow-up for intervention vs control conditions.

RESULTS

Of 5,145 articles identified, 34 articles (with 43 treatment-control comparisons and 4,176 participants) met methodological standards and were included. The overall pooled g with winsorized outliers was 1.01 (95% CI = 0.72-1.29, p < .001) at post treatment and 0.68 (95% CI = 0.29-1.07, p = .003) at follow-up. Interventions delivered by professional clinicians significantly outperformed those delivered by lay providers (g = 1.59 vs 0.53), but all interventions for conduct problems were delivered by professionals, and the difference for interventions targeting internalizing problems (g = 1.33 vs .53) was not significant. Interventions developed non-locally were more effective if they were not adapted to local contexts than if they were adapted locally (g = 2.31 vs 0.66), highlighting a need for further research on effective adaptations. Significant risk of bias was identified.

CONCLUSION

Overall, pooled effects of youth psychotherapies in LMICs were markedly larger than those in recent comparable non-LMIC meta-analyses, which have shown small-to-medium effects for youth psychotherapies. Findings highlight the potential benefits of youth psychotherapies in LMICs, as well as a need for more RCTs and improved study quality.

Parental migration status moderates the link between parent-child relationship and children's well-being through psychological distress

The effects of parental migration on the well-being of left-behind children (LBC) are varied. Several studies demonstrated that parental migration reduces children's psychological health but other research showed contradictory results. This study sought to clarify this issue by examining the mediating role of psychological distress and the moderating role of parental migration status in the association between the parent-child relationship and children's psychological distress. A total of 743 LBC and 688 non-LBC self-reported their parent-child relationship, psychological distress, and well-being. Findings showed that psychological distress mediated the association between parent-child relationship and children's well-being. This denotes that greater parent-child relationship results into lowered levels of psychological distress, and in turn, increases children's emotional, psychological, and social well-being. Moreover, the link between parent-child relationship and psychological distress was found to be contingent to parental migration status. Specifically, the negative association between parent-child relationship and psychological distress was especially strong among LBC in contrast to non- LBC. This implies that children with higher quality relationships with their parents tend to exhibit decreased severity of psychological distress symptoms, especially in children whose parents are working overseas. These results underscore the dynamic role of parent-child relationship in the well-being of LBC, and suggest ways to develop intervention programs that include cultivating skills in managing psychological distress and improving the emotional, psychological, and social well-being of LBC.

Guided self-help Urdu version of the living life to the full intervention for secondary school adolescents with low mood and anxiety in Pakistan: A feasibility study

There is limited evidence on the efficacy of Cognitive Behavioral Therapy (CBT) based guided self-help programs to improve low mood and anxiety in Pakistani adolescents. The aims of the current study were to assess the effectiveness of an eight week low intensity CBT-based guided self-help program, Living Life to the Full (LLTTF) on depression, anxiety and social functioning among secondary school adolescents in Pakistan. Fifty-six participants were randomly allocated to immediate (n = 28) and delayed access (n = 28) groups. Measures of depression, anxiety and social functioning were collected at baseline, post intervention and three months follow-up. There were significant improvements in measures of depression (t = -3.47, p < 0.01; d = 1.0), anxiety (t = -6.55, p < 0.001; d = 1.91) and social functioning (t = -4.28, p < 0.001) between immediate access and delayed access groups. These differences remained significant at three months follow-up. The study suggests that the Urdu LLTTF book course delivered in classes is effective for reducing depression and anxiety as well as improving social function among adolescents in Pakistan.

Preliminary evaluation of a culturally adapted CBT-based online programme for depression and anxiety from a lower middle-income country

Online cognitive behaviour therapy (CBT), self-help and guided self-help (GSH) interventions have been found to be efficacious and cost-effective for treatment of anxiety and depression, but there are limited data from low- and middle-income countries on culturally adapted digital interventions for these common mental disorders. The aim of this study was to investigate the feasibility and acceptability of an online culturally adapted CBT-based guided self-help (CaCBT-GSH) for patients with anxiety and depression in Pakistan. This randomized controlled trial recruited 39 participants from primary care in Karachi, Pakistan and randomized them to two groups. The intervention group received seven modules of CaCBT-GSH plus treatment as usual (TAU) over 12 weeks. The control group was a waitlist control plus TAU. The primary outcomes were feasibility and acceptability. Clinical outcomes included results from the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHODAS 2). Assessments were carried out at baseline and at 12 weeks. All 39 individuals who met eligibility criteria for the study agreed to participate. Adherence to the intervention was excellent, with 85% (17/20) completing more than five modules. Statistically significant improvements were found in all clinical outcomes in the intervention group. This was the first trial of an online CaCBT-GSH intervention, which was found to be feasible and acceptable to Pakistani patients with anxiety and depression. CaCBT-GSH may help improve symptoms, depression, anxiety and overall functioning in this population. The results provide rationale for a larger, confirmatory randomized controlled trial of digital CaCBT-GSH.

Key learning aims

(1)