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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Nature of Mental Imagery and Its Relationship With Amotivational Psychopathology in People With Schizophrenia Spectrum Disorders

Many people with schizophrenia spectrum disorders (SSDs) experience profound amotivation, which is strongly related to anticipatory anhedonia. Yet, the neuropsychological fundamentals of anticipatory anhedonia and amotivation are barely understood, resulting in a lack of effective treatments for these patients. Aberrancies in positive mental imagery may interfere with the anticipation of pleasure and could thus explain anticipatory anhedonia and amotivation. However, the nature of mental imagery and its relationship with amotivational psychopathology in SSD is largely unknown. In this preregistered study, we therefore examined mental imagery characteristics and their relation to anticipatory anhedonia, amotivation, and daily life activity in SSD. TheN = 86 participants included individuals with SSD (n = 43) and demographically matched healthy controls (n = 43). Mental imagery, anticipatory pleasure, amotivation, and activity engagement were assessed with structured interviews and self-report questionnaires. Ecological momentary assessment was used to measure state anticipatory pleasure and activity engagement in daily life (n = 81). Compared to the control group, the SSD group showed comparable quantity, but less vividness of mental imagery. Reduced vividness of mental imagery in SSD was significantly associated with higher anticipatory anhedonia, amotivation, and low activity engagement in cross-sectional and prospective analyses. Reduced mental imagery vividness may cause a lack of internal incentive to seek pleasurable experiences and could explain amotivation. Interventions aiming to improve mental imagery vividness and related anticipatory pleasure responses in SSD may be effective in targeting amotivation.

Transdiagnostic and transtherapeutic strategies for optimising autobiographical memory

Our memories for past personally experienced autobiographical events play an important role in therapy, irrespective of presenting issue, diagnoses or therapeutic modality. Here, we summarise evidence for how autobiographical memory abilities can influence our mental health and the relevance of this for the treatment of mental health problems. We then guide the reader through principles and strategies for optimising autobiographical memory within treatment. We ground these recommendations within research for stand-alone interventions for improving autobiographical memory and from studies of how to support the formation and retrieval of therapeutic memories. Options are given for clinicians to guide clients in improving retrieval of autobiographical memories within treatment, for improving autobiographical memory for the therapeutic experience itself, and for creating improvements in autobiographical memory that endure post-treatment. We also provide worksheets for clinicians to use within treatment.

Future thinking and anticipatory pleasure in adolescents with major depression: Association with depression symptoms and executive functions

OBJECTIVE

Impairments in episodic future thinking and anticipatory pleasure were noted to explain the depressive symptoms in adults however similar studies are not there in adolescents. This study examined whether there are impairments in episodic future thinking and anticipatory pleasure in clinically-depressed adolescents as compared to non-depressed adolescents, and their association with depression when controlled for executive functions and anxiety symptoms among the depressed adolescents.

METHODS

The study included 29 adolescents with major depression and 29 adolescents from local schools through convenient sampling technique. All the participants were assessed with standardized measures of depression and anxiety, episodic future thinking, anticipatory pleasure and executive functioning.

RESULTS

Depressed adolescents significantly differed from the non-depressed adolescents in autobiographical memory specificity, anticipatory pleasure, and specific dimensions of executive functions. The ANCOVAs indicated executive function slightly attenuated group differences on future specificity which were still non-significant (all p's > .05). For memory specificity and for anticipatory pleasure, group differences were still significant at p < .05 level.

CONCLUSION

Adolescents with major depressive episode may display similar, but less pronounced, impairments in future thinking than what is previously reported in adults. Though, autobiographical specificity is prominent. The deficits are attributable to depression than executive functioning deficits.

Drinking to Cope is Uniquely Associated with Less Specific and Bleaker Future Goal Generation in Young Hazardous Drinkers

Groups with mental health and/or substance use problems generate less detailed descriptions of their future goals. As substance use to cope with negative affect is common to both groups, this characteristic might be uniquely associated with less specific goal descriptions. To test this prediction, 229 past year hazardous drinking undergraduates aged 18-25 years wrote about three positive future life goals in an open-ended survey, before reporting their internalizing (anxiety and depression) symptoms, alcohol dependence severity and motivations for drinking: coping, conformity, enhancement and social. Future goal descriptions were experimenter-rated for detail specificity, and participant-self-rated for positivity, vividness, achievability, and importance. Effort in goal writing was indexed by time spent writing and total word count. Multiple regression analyses revealed that drinking to cope was uniquely associated with the production of less detailed goals, and lower self-rated positivity and vividness of goals (achievability and importance were also marginally lower), over and above internalizing symptoms, alcohol dependence severity, drinking for conformity, enhancement and social motives, age, and gender. However, drinking to cope was not uniquely associated with reduced effort in writing goals: time spent and word count. In sum, drinking to cope with negative affect is a unique characteristic predicting the generation of less detailed and bleaker (less positive and vivid) future goals, and this is not due to lower effort in reporting. Future goal generation may play a role in the aetiology of comorbidity of mental health and substance use problems, and therapeutic targeting of goal generation might benefit both conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10862-023-10032-0.

Difficulties in retrieving specific details of autobiographical memories and imagining positive future events in individuals with acute but not remitted anorexia nervosa

INTRODUCTION

The factors that contribute to the maintenance of anorexia nervosa (AN) are not fully understood, although it is generally accepted that depression is a core feature and contributes to poor prognosis. Individuals with depression tend to have difficulties in producing specific details of autobiographical memories and future episodes. Our aim was to investigate autobiographical memory and episodic future thinking (EFT) in individuals with AN (n = 46), people recovered from AN (recAN; n = 40), and non-affected controls (n = 35).

METHOD

Using a remotely administered computerised version of the autobiographical memory test and episodic future thinking task, we measured six aspects of memory retrieval and EFT generation: specificity, detailedness, difficulty in remembering/imagining, positivity, vividness and realism. Memory and EFT cue valence was manipulated; cues were either positive, neutral, or disorder-related/negative. As the production of EFTs is theoretically linked to the ability to retrieve autobiographical memories, the relationship between autobiographical memory specificity and EFT specificity was explored. To investigate whether autobiographical memory and EFT performance were independent of performance on other forms of cognition, working memory, verbal fluency and cognitive flexibility were measured.

RESULTS

People with AN had difficulties retrieving specific details of autobiographical memories and rated autobiographical memories as less positive overall, and less vivid when primed by positive cues. People with a lifetime diagnosis (currently ill or recovered) reported greater difficulty in retrieving memories. The AN group generated less positive EFTs, particularly to positive and neutral cues. Comorbid depressive symptoms had some contribution to the observed findings. Lastly, in all groups autobiographical memory specificity predicted EFT specificity.

DISCUSSION

Problems with retrieving specific details of autobiographical memories and simulating positive EFTs may be a state feature of AN. Treatments targeted at alleviating depressive symptoms, as well those targeted towards facilitating memory retrieval or reconsolidation, and the construction of positive EFTs, may contribute to hope for recovery and strengthen the sense of self beyond the disorder.

Reducing Anhedonia in Major Depressive Disorder with Future Event Specificity Training (FEST): A Randomized Controlled Trial

Background

Improving future thinking, such as characteristics of specificity, detail, and use of mental imagery, may be one means to reduce anhedonia, particularly in a Major Depressive Episode (MDE) in which future thinking is impaired. The current study aimed to test this using a validated program, Future Event Specificity Training (FEST).

Methods

Participants (N = 177; 80.8% women; M age = 43.7, SD = 11.8) with a current depressive episode with anhedonia and high symptom severity were randomized to FEST or no FEST. Future thinking, anhedonia-related variables, and other clinical outcomes were assessed at baseline, one- and three-month follow-up.

Results

Relative to the control group, FEST was associated with significantly improved future thinking characteristics, a reduced likelihood of anhedonia (35.1% vs. 61.1%, p = .015), improvements on other anhedonia-related variables such as anticipatory (d = 0.63, p = .004) and anticipated pleasure for future events (d = 0.77, p < .001), and desirable clinical outcomes such as less people meeting criteria for an MDE (37.8% vs. 64.8%, p = .011), higher behavioural activation (d = 0.71, p = .001) and improved global functioning (d = 0.52, p = .017). Changes in future thinking were found to mediate the effect of FEST on anhedonia.

Conclusion

The quality of future thinking can be enhanced in Major Depression, and this leads to a substantially reduced likelihood of anhedonia, other significant clinical effects, and functional gains.

Episodic Future Thinking in Autism Spectrum Disorder and 22q11.2 Deletion Syndrome: Association with Anticipatory Pleasure and Social Functioning

Episodic future thinking (EFT) has been suggested to underlie anticipatory pleasure (AP), itself known to play a crucial role in social functioning (SF). Both AP and SF are impaired in various clinical populations, including autism spectrum disorders (ASD) and 22q11.2 deletion syndrome (22q11DS). Therefore, the relationship between EFT, AP and SF was investigated, as well as the potential role of projecting oneself in a social vs. non-social context. Seventy-seven participants [24 with 22q11DS, 20 with ASD, 33 typically developing controls (TDs)] (aged 12–25) were included. They were assessed with a future thinking task in which they were asked to recall a memory and produce a likely event. Narratives were rated based of specificity, richness and imaginability. Participants completed questionnaires assessing AP and SF. Narratives from ASD and 22q11DS participants were rated as less vivid compared to TDs. However, the characteristics of the narratives differed between ASD and 22q11DS participants in terms of specificity and level of details, as well as in reaction to social condition. Moreover, correlations were found between AP and EFT in both ASD and 22q11DS participants, and between SF and EFT in ASD participants. These results point towards impairments in EFT in both ASD and 22q11DS participants but with a specific profile in each condition. The observed associations between EFT and AP suggest that decreased autonoetic consciousness might underlie AP impairments. In ASD individuals, the association between SF and EFT highlights the need to better characterize EFT since EFT could be another mechanism contributing to social difficulties.

Changing the future: An initial test of Future Specificity Training (FeST)

A range of psychiatric disorders are characterised by impairments in episodic future thinking (EFT), and particularly simulating specific, spatiotemporally-located future events. No study has examined whether training can lead to sustained improvement in specific EFT. In this study, participants (N = 60; M age = 31, SD = 13.2) were randomized to a two-session, group-based future thinking program (Future Specificity Training; FeST) or wait-list. At follow-up the training group, relative to wait-list, showed large, statistically-significant improvements in the ability to mentally simulate specific EFT (d = .82), increases in detail (d = 1.32), use of mental imagery (d = 1.32), anticipated (d = 1.78) and anticipatory pleasure (d = 1.07), perceived control (d = 1.20), and likelihood of occurrence (d = 1.09). Some effects were also observed on positive, generalised future self-states. In the context of inherent limitations of subjective reporting in trials, this study provides evidence that EFT specificity can be enhanced, and the effects of FeST indicate a possible avenue to disrupt psychopathological processes.

A study protocol for a randomised trial of adjunct computerised memory specificity training (c-MeST) for major depression in youth: targeting cognitive mechanisms to enhance usual care outcomes in mental health settings

Background

Youth depression is highly prevalent and is related to impairments in academic, social and behavioural functioning. Evidence-based treatments are available, but many young people do not respond or sufficiently recover with first-line options, and a significant proportion experience relapse. Consequently, there is clear scope to enhance intervention in this critical period of early-onset depression. Memory specificity training (MeST) is a low-intensity intervention for depression that targets reduced specificity when recalling memories of the past, a common cognitive vulnerability in depression. This randomised controlled trial will assess the efficacy of adding a computerised version of MeST (c-MeST) to usual care for youth depression.

Methods/design

Young people aged 15–25 years with a major depressive episode (MDE) will be recruited and randomised to have immediate access to the seven session online c-MeST program in addition to usual care, or to usual care and wait-list for c-MeST. The primary outcomes will be diagnostic status of an MDE and self-reported depressive symptoms assessed at baseline, 1-, 3- and 6-month intervals. Autobiographical memory specificity and other variables thought to contribute to the maintenance of reduced memory specificity and depression will be assessed as mediators of change.

Discussion

Online provision of c-MeST provides a simple, low-intensity option for targeting a cognitive vulnerability that predicts the persistence of depressive symptoms. If found to be efficacious as an adjunct to usual care for depressed youth, it could be suitable for broader roll-out, as c-MeST is highly accessible and implementation requires only minimal resources due to the online and automated nature of intervention.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12619000234112p. Registered on the 18 February 2019. All items from the WHO Trial Registration Data Set can be found within the protocol.

Protocol version

1.0

Impairments in episodic future thinking for positive events and anticipatory pleasure in major depression

BACKGROUND

Characteristic of the cardinal symptom of anhedonia, people with clinical depression report lower levels of anticipatory pleasure. However, the psychological mechanisms underlying these deficits are poorly understood. This is the first study to assess whether, and to what extent, phenomenological characteristics of episodic future thinking for positive future events are associated with anticipatory pleasure among depressed individuals.

METHODS

Individuals with a Major Depressive Episode (MDE; N = 117) and without (N = 47) completed ratings scales for depressive symptoms and trait anticipatory and consummatory pleasure. They then provided descriptions of personally-relevant positive future events and rated them for phenomenological characteristics and state anticipatory pleasure.

RESULTS

Between-groups analysis showed that those with MDE reported lower trait anticipatory and consummatory pleasure. They also simulated future events with less specificity, less detail/vividness, less use of mental imagery, less use of first-person perspective, less plausibility/perceived likelihood of occurring, and reported less associated state anticipatory pleasure. In regression analyses in the depressed group, lower scores for detail/vividness, mental imagery, and personal significance all uniquely predicted lower state anticipatory pleasure.

LIMITATIONS

Cognitive functioning was not assessed, which may help clarify deficits that underpin these findings. History of previous depressive episodes in the comparison group were not assessed, which may mean the observed between-group effects are underestimated.

CONCLUSIONS

This study provides further evidence of deficits in episodic future thinking and anticipatory pleasure in depressed individuals. It also establishes links between particular characteristics of episodic future thinking and state anticipatory pleasure, and indicates cognitive targets that may be amenable to intervention in order to reduce anhedonia.